ROLL
VJiS.
Vf'
f*
â– /
(
,.& ,,,1.1*
Vr
LOCAL I T Y
RECORD S
RECORD
SAN FRANCISCO
COUNTY
CERTIFICATES
..)
r
•v ,'
M I CROP I LMED
TH E GENEALOG ICAL
SALT
CA L I FORM I A
DATE
APRIL
PH OTOGRAP HER
MAX JOHNSON
CAMERA
no2683Hred 1
yo
''"«N>.
EGIN
)'iW^'
i
t
5t.
••»
« V
t / ;* .
••
i,b«r <^ ^'
V <. '*^~WV.
/\
Jj/
DfiFUTY.
I
rfl-
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Board of fUalth- I- No i- "^-^^S^UiKV Co
REFER TO BACK OF CEWTiriCATC FOR INSTRUCTIONS
IW.
290\
I)(ffr Fi/e(/,
(LiyoL.^ cLov-t<. Deputy Health Officer
Jie^istcred J^o,
1010
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( "CI. S. StanC»arC> )
4
%
PLACE OF DEATH: — County of OOyW; JA.'avvc\.acc. City of'^'-O-A^ >J.>UX-v-a^
'No.
A SO MUvtlA.Mcv,.i
^^. c_ c
St.; I Dist.;bet. cLCL>\^VLla\; and OvLVicL-
/ .r OC*TH OCCURS *W*V FROM USUAL R E S I D E NC E G I VE FACTS CALLED FOR UNDER "S PEC I AL I N FO R M ATIO N < \
V .r DEATH OCCURRED ,N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STR E J! AN D N U M " « )
FULL NAME
oj\.A.cL' v^Ll
PERSONAL AND STATISTICAL PARTICULARS
DATK ni Itik 111 0
A(.K
fVear)
\X\JX^^\
MEDICAL CERTIFICATE OF DEATH
DATE OK DKATH /"I
L
(Month) \
(Day) (Year)
i
I )â– -.;,
11
M.mth
/'<
/ 1 A
'^iNi.i.K MAkun;i>
\\ iDow i;i> (IK iM\ I >krKi>
(Writtiii siH-ial <lt si^'iialion)
MIK llll'l.Ari-:
' State or l"i)unt r\' '
NAMK <U
FA I 111. K
lUk lUlM.ArK
Of- lATMKk
'State r)r CiMiiit r \-
MAIDKN NAMi:
<)!• MoTHKk
nik riii'LAr}-.
<>i M< nil Ilk
'State or t*(»miti\ I
I HI'KI'HV C1;RTIFV, That I attetided tleceased from
•H "^ Itp'- to LL.^...|..^ T^p'l
that I last saw h •. alive on LL"..\„n • j^q
ami that death occurred, on the date stated above, at 1
\i M. The CAISK OF III^ATII was as follows:
rOLh-xCrL
<1 J 'I'.'AA.
i
JL'^'v^*>va/v
1
-I
I )r RATION Yt'ars
CONTRIIU'TORV
Mo)iths
Da v.v
Hours
\^ \
V, r V<.. ^
1 . ^ .
DTRATION 9v r/V7;'5 JA>;/M.?
(SIGNED) Jyi^-ft-^VUX^ WcrL^ci
dv.., o
I()0
Pays
T Q . V
flours
M.D.
( A d<l ress) (o ^H U 3 <X\.N„L-l if'. ■J '^
Special information only for Hospitals, Institutions, Transients,
or Keccnt Residents, and persons dying away from home.
OCCrPATlON
M;>,fll^
/),n.
IHI-: MjdVK sTAri:i» I'KksoxAi, i-xk ri.ri. \ks aki; rki k tm rin-:
iihsT OF Mv kv()\vkj:i)(,f: and iu:i.n:i-
'I
"f..rinat.t UJ OjLdLX'^V>
^^
\<l<Ii(
former or
Usual Residence
Wfjen was disease rontrarted,
If not at plare of death ?
Hew lonq at
Place of Death ?
Oavs
DATlv (jf niRiAr, or KKMOVAI,
wq i'!.
I'l.ACK OF" lUKIAI. OK KF:Mo\ \1,
indf:rtakf:k VI V O A-<Xvi . '^'^-^ â– (.
(Address 5..S.1. 0-^\XLjL^ .C!±
o ^0
190 1
^- ^- Kvery item of infopmution should be carefully Hupplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for p«r-
«on« dyin^ away from home should be |»iven in every instance.
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
J<n:ii(! <if !!( :ilt)i \' Vo. i ', *'^v5«?^5^ US;, I' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Ihf/c Filed,
I V
Deputy H
100\
Officer
Be^Lstcj'cd J\^o.
1020
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Deatb
( XX. 5. Stan&at? )
PLACE OF DEATH; — County of J<Xa\) J/v<X >VCt^C(. City of OoyTu 0;uX/>vculcc
'No.
blo
v(X,\.|^J.
St.
5^ Dist.;bet* ll ^ and IXfrXXk.
r \r Dt4TM OCCURS *w*v rnoM USUAL RES I DENCE Givt facts called for undfr "special information- \
V if death occurred in a hospital or institution give its name instead of street and number. )
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
SKX
DAi}-; «>1 IllKTlI
OJJL
COI.OR '\
\
?
1
•Moiithl
A<,K
I 1 )ra>>
(I):iv)
M..iilfts
(Year)
n,i \s
OJUu
SFNi.I.H, MAKKIHI).
W inoWKI) OK DIVoKiKl)
(W'litriii >-<)ti,'il <ltsij.'ii;iti<)ii)
lilK rni'l.ACH
(St.'itf or i/oiiiitry)
\AMi-: Oi-
l-ATM i;r
HIK rHI'LAiH
OI-" iAini-:K
(Stat( or I'oiiiitry)
MAM)I-:\ NAM I.
oi" .mothi-;k
HI KT HIM, An-:
OI-- MnTin-;K
(Statt.- or Coiiiilry)
OCCri'ATlON
MEDICAL CERTIFICATE OF DEATH
DATE OK DKATH -^
(MoiUh) (| (Day) (Year)
1 HIvRHBY CERTIFY, That I atten(T^.r(lcrca^>(rfroni
up - to LL*.^oOb ^^ 190 H
that I last saw h.7AL>\J alive on vAa^^a^q; IC- joo'i
and that death occurred, on the date stated above, at '0-^0
U^M. T^ie CAUSK (.)!• DIvATII was as follows:
1
•C L ^.
DTK ATI ON Id )'ears
CONTKIHUTORY
Man tin
Da vs
I /ours
A.
hi
O
CL^^^V1
DIRATION
INED) M/L
(SIG
V
dU
:iAl in
}'cars Jfoj/Z/is Days Hours
90 1 (Address) S.JoS UXX^v A.>{Xvl<N.
O /CX^^j^kxM_ M.D.
?''^9'^^ Information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
VM-V,A. I '^- T 00 ' 1 r A d d ress ^ 1 (c S O /a/^^ s \J\X I /V 0 (J, .
Mnuth^
Ihl
rm-; ahovk st\ti:i) pkksonai, paktuti.aks \ki-- tkik to tiii--
IIHST Ol- MY KNOWM-DC.H AM) UKMl-iF '
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
Hew long at
Place of Death ?
Days
ill
Q%v.
VOlm
r\fl dress
bio
Vh.KQV ()!• lURIAI. OR RHMoVAI, I DA'IMv^of Hr«,Ai. or KKMOVAI,
^% Crlw-L^uo-^i^ I CLwv^....a. T9o'i
INDKRTAKER
^^
(Address 1^1 \l fAA-^^A-V^^O
t
""' ^'~^tBU CXU^t Ov7r^^^^ 1" '■«-«*"">' Hupplied. AGE «houId be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH m plain terms, that It may be properly classified. The "Special Information" for dt-
son.dym^ away from home should be ftlven in every instance. â– mormaiion for per-
f
!
t
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Hoai.1 of Health » Vo I ■. T^^|S^ H& I' Co RCFCR TO BACt{ OP CERTIFICATE FOR INSTRUCTIONS
|(<5 lOO'i
cMro_A^ ckX'XMH^ Ljcp'ut, - . , Officer
Begiatered J^fo.
1021
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
( XX. S. Stan&ar? )
PLACE OF DEATH: — County ofOoL/\X) vJAXXAvcM-^/C^City of ^^O.yVu J XXX >V/Ca.<l.c<.
^No.
0 JL\yY>xxx>v
(KL.
â– \0^
O.
St,; — — Dist; bet/
and
f IF DtATH OCCUBS *WAV ^ROM USUAL R E S I DE NC E Gl VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION'S
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
•'^HV A ,. A I COI.OR
XL>^^LC
:t
DATK nl HIKTII
AC.K
^â– OJ
CAJL
MEDICAL CERTIFICATE OF DEATH
^V\j
<M<)iith)
\- N ) I II I .
(Dav)
.!/.»;////>
Ml
(Year)
/)>n>
SINC.I.K. MAKKIKI).
WIDOWT.I) OK DIVom K.r)
lU'iitt ill >.(>cial dtsij.riiatioii)
lUKTHIM, Xrj-:
(Slatr or c*<nintr\)
FATin.K
lUK rniM.ArK
()!•■I ATHKK
• Stal< or l"oimtr\>
maii>i;n namj:
«»J- MOTHF.K
HIRTHrUACK
1)1- MOTMKK
(State- or Countr\
DATK OI" I)1:ATH /"^
(Month) ^
I 1II:R1':HV CI':RTIFV, That I atten.lc.l .Icccased from
(Day)
/go
(Vtar)
-V. \ \„^_
i I f
190
to
tliat I last saw h -^i/vw. alive 011
I
^
Uw..A..A^
190 H
and that death occurred, on the date stated above, at X-'^L
-^ ^I- 'I'lK- CAISH Ol' I)I-;aTII was as follows:
}'ears '. Mouths
.'ONTIillU'TORV \J
DIRATION
Da vs
crV ^SsAA^'v-.o,
Hours
occ
nr RATION
(Signed )
^O.yftw^VW^-:^.
)Vr7;-5 Mouths ^ /^//v.v
'vKa/vv^
/fours
M.D.
VAx/^q^ 15 TQo 1 (Address) UXVwvQ^v K ^v'J, j.
f\f^idfi{ ill S(i>/ i'ltiu,
) V(M
Miiuthy
I >a \
TUK AROVK STAT)-,I) I'FKSonm, J' A KTI.T i. \ k S Xkl- TKIK To
IIKST OF MV K\o\VM:I)(;k AM) in:MKF
TH1-:
(I II forma lit
O X^v/^^vA/cx^v Jb 0-<i.'i'V\jtvtx.l.'
?''^9^fi^."^^Of"^'^T"'ON only for Hospitals, Insfilutlons, Transients,
or Recent Residents, and persons dying awav from home.
., .n"^,. (O I." D Howlonqat
Usual Residence WoJkXo..v-^ ' Place of Death ? . .. Days
When was disease contracted,
If not at place of death ?
'X.Mrt'ss —
I NDl.KTAKHK
(Address
T90
y/^-^^^'''j> "IK'-^I. OK KFMOVAI. DATKo; Hikiai. or KKMOVAI.
m (? y
(D 'cvk.itx,.>x^ Lx.L,
"^' "■~rt«Te''clr*s?Ap*nTri'M" •*'7'*' "^^ ^"-«»^""y «uPPi-d. AGE «houlcl be stated EXACTLY. PHYSICIANS .hould
state CAUSE OF DEATH m plain terms, that It may be properly clarified. The "Special Information'* for D.r-
«on« dyinft away from home should be ftJven in «very instance.
r
WRITE PLAINLY W|TH UNrAniMi^ iiviv
I k #* » • •
Ho;t!'l of Ifc.'iltli !•* No. i^ t*^^5S^ WScV Va
l)(((r Filed,
'^UV'V^
RgFER TO BACK OF CERTIFICATg FOR INSTRUCTIONS
\h
190\
Registered JVo.
1022
AM^
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH-Cify and County of San Francisco
Certificate of ©eatb
PLACE OF DEATH: — County of vJXa.cxx.\
City of
(No,
St.;
Dist; bet. ~
and
( " ,v.r.,:%c"c-!.;ro',^-r„<.".-- t^^:^^^-:-^'iti^i:::.-v; ,;%%%Ti„TS;r- )
FULL NAME
A.<VxLcui I.:
L-
si:\
PERSONAL AND STATISTICAL PARTICULARS
'f
DATK nl' MIK 111
AC K
LUJva
Ll.lvVA.i
I Mont'li )
1
) III I
H
(Day)
M.-ut/is
JL
(Year)
I (;
n,7 v.s
SIN(.I,K MAKKIHI)
\vii)n\vi:i) OK i)!\()Kri;i)
(Wiitriii MK-ial <l«sivMijiti<.)i)
lURI'ni'UAOK
'State or Coiiiiti v)
NAMI-: <)}
fatiii:k
HIRTMI'I.AiH
OI- l-ATUHR
'State or Country)
maii)i.;n namk
<H- MOTHKK
niR'riiiT.ACH
Of MOTHKK
(Stat.- or Cotintry)
'^-XxJ^CL^y^^J
MEDICAL CERTIFICATE OF DEATH
DATE OK DKATH
(Day)
(Month)
(Year)
I HIvRIvHV ClvRTIFV, That I atte„<le.l .lercased from
^90 ■to T90 —
lliat I last saw h .Tr-r-r~ralive on .. ^^
and that death occurred, on the date stated al)ove, at -
.^^n '^^^ CArSiC OF J)|.;ATII was as follows
'%ju^>Oi^ ^I^.
Dr RATION }'(^ars
CONTRIIU'TORV
Mouths
Da vs
//oius
DTRATIOX
y't'ars
C ^'â– J<.U
\\jJLaxs x ci
Over PAT ION
^'f^idfii ni .S\i,r /'nnui\,;> C>\> )'r,n y
(Signed)
ECIAL IIM
.Vi)/i//is
Pa vs
JVcva. Y\.t
^1
90
(A(Mress) J Xa^.> a4^,« J, v . O ' .
//ours
M.D.
."^^'iifh^
Ihn
"'''r^^^'i'i^i:.^'^^::^^^^^::^:^^^
flrfprrn^^P^i;;J'^„J'°'''^?T"ON ?"'y f«r "ospita'S Insfitutlons, Transients,
or jfcent Residents, and persons dying away from home.
Former or % () P 0 H«v
Usual Residence \J Kk^^JL^^JUL, Kxxh pi^j
When was disease contracted,
If not at place of death ?
.a
y^« Days
f rnfotniatit
.9
Address O A.A.,A^-Q^HK_C
i'i.A^y>K mRrAx „k rkmovai. | D-vaCof H.-k,.,. or kkmovai.
.<u
I • N D 1 : R T A K I.; R jfo oXaXjlS^
I90H
(Address ...
r »
-^^dSS.
i^x
m
i|
i
WRITE PLAINLY WITH UNFADING INK— TWic: i
tk DCDtmAKlPKI-r- r% w» ^^ ^s. r* w^
Mo.-IIil of
Hr.iltli- K No. K "^^^^^ US: I' Co
REFER TO BAC»^ OF CERTIFICATE FOR IN3TRUCTIONS
Deputy Health Officer
Registered J\^o,
1 02;
DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco
Certificate of S)eatb
( la. S. Stan^arO )
PLACE OF DEATH.— County of Clcx^ 0 AXXoxCvaccCity of 0,CU^3xa.^
'No. 110 5 \i n.
'V<lCvlC.(.
-A<i V. c >
.d
FULL NAME
St.; Dist.;bet. IT .A^\; and
â–º IDENCEgive facts called roR under "special informatio
OR .NST.TUT.ON GIVE ITS NAME .NSTEAO OP STR E ET AN D N u M " «
I. n
( " .v*o;".,°„=^c"c"j,;ro\;."rHo",^pr.t c%^fj^^?u';Li"/,/«:!^.vi.^° -".--!' i--- .-o".t..,o... ^
\IU
\,
)
si:\
PERSONAL AND STATISTICAL PARTICULARS
I COI.OR
>J,
1/ .
iJx
i>Aii- <)i liik ru
AC.K
iMoiitli) K
]
MEDICAL CERTIFICATE OF DEATH
!'â–
) ra I >
Moulhs
(Year)
n,t\
DATE OF 1)K.\TH r\
(Month) K
i:i
(Day)
(Year)
I HKKICHV ClvRTlFV, That I attcmlcl .IcHcased from
..U^Q U igo S to SAA/vn
that T last saw h .. alive on LL
...IH.
SIXC. 1,K. MAKKIKD
wii)()\y}:i> Ok i)[voKri:i)
(W'titi' in v.,HiriI il< si^'iiation)
lUK'rm'i.AOH
'St.iti- or Comitrvi
\\M1-: OI
HIKTIllM.ArF:
OI' I ATMKR
iSfatr or Couiiti v
<4 I
aiKl that death wcurred, on the date stated aln.ve, at 1 \
M. The CAlSlv OF I)1;aTH Nvas as follows:
()v>^\.ivJL>''vjt
vXXAXx.v
CL'-^
* -V\ i^JC'''>
.V^:
\
ihr.\tion
MAIDKN NAM1-:
oi- M()thf:r
nikTiii'i.ArF:
oi- m()Thf:r
(Sialt or Cojiiitry)
-^ '^font/is Days
//ours
AJouth^
l^avs
//ou
<r^\
I )r RATION . Years
( SIGNED ) Aj^j^A, U UA..av> M c
^u^a il ,(
â– <\ Iv I()0
Address) V.^ 11). O
M.D.
â– A- V^X^-> X '
«r?''^9'^^. "^^O^'^A'T'ON »"'> f"*^ Hospitals, Institutions Transients
or Recent Residents, and persons dying away fro.-n home. '"nsients,
Kf.^idnl 1,1 S,ni /'i ,ni,/.u;> ['X ),-,r
^â– >iitli<
/hi v.
rwv. amovf: sta ii-.d i'kksowi FXR-rrriM au< iot.- i-Di-t.' ■,. — ~!
lU-SToF MY KNN.\VlJ.:iM-.K AN,) MHilij.ii'''^ ^'*^- ^^^ ^- '<' 'IIH
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
Hew lonq i\
Place of Death?
Days
(Info/maiit
'Address ^lOS \l /U^^
v\;
I90H
N. B.-
'"'f7^7' ""l "^'%''' '"" KK.MCVAI, I nAi;F of HrK.A,. or RKMOVAI,
.on. d,i„g aw», fro™ h„„e Should hTtiven ?„ '.v.'.T uZT. ' '""''>"'■■^*" "«-"-' ""fo—ion" for p.r-
#*«"â–
WRITE PLAINLY WITH UIMFAniNn ink -ruie
• •«»• » %^ f-» I ^r-iiTir^i«E.ivl
laa M Ikl r* iki^- m^ mm ^^ ^m. mm ^,
Jtoiiid .if ll(;ilt)i I- Vo n -^'^^SiOj^I^ H^l' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Registered JVo,
io;24
'XAjx)^ Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and Counfy of San Francisco
Certificate of 2)eatb
( m. S. StanOarD )
PLACE OF DEATH: — County ofCJ/a-^ J.fLCL^n^^ivxw^oGty of Oo^vv i>La.. vci-;i.cc
'"^^ ' '^ .V,;:.:: ;cc„.s ^t.: I Dist., bet. O KXX^x^^L ^nd J -cll L- J .
'No.
)
FULL NAME
dA.^'v"J- ^ .
PERSONAL AND STATISTICAL PARTICULARS
'^'•^ (J?) (j j COLOR \
n.\'n-; <n- iukiu (y>j a
x^
I Month)
AC. F,
) Vi/> >
(o
1-5
(iJav)
Motilfif
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH , 1
U,A. v.,n 1 5-
(Month) (
(Day) (Year)
(Vt-ar)
/hi v.v
siN'r.ij.:, MARun:i)
WIDOUFI) OK DIVoKiFI)
iWiitrin M>rial <h-si^^iiatioii)
lURPMlM. M'F
(Stall or rotintiv
NAMF »H-
fathi:k
niKTHI'I, \(H
OI- lAIIIKK
(Statt or I'oiintrv)
MMDl'lN NAMF
<»1 MOTFIHK
niRTHI'I.ACF,
oi- MOTMHK
(State or t'oiintry)
I HHRI-:i'.V CKRTIFV. That 1 atten.k.l <lcr.ase<l from
^^^-C^ V 190 'i to . .LLi.v.CL LL i^ ,
that I hist saw h ... .â– alive on UoVa^c^ ' i^o
and that death occurred, on the .htlc stated above, at ^
A] M. The C.\rSH OF DIvATII was as follow.s
^^^CX-Ivv-^UL-Ol*
I
'-^
occri'A riox
cjO
'<X '^vv-L
.L
nrR.ATiox
(Signed )
Years
OIL I
3 (.Athlress) H'ia T^U A \ I O-M -J
Hours
M.D.
44-
/^</ 1 A
Tin: AHOVF STAIl-I) I'KKSONAI, I'AKTItM" I AKS XRFTKI-V n » rii.^
HKST (>!• MV K.NOWI.FDC.K .\nI) nKMKF ' ' ' * ' " '*'
nr?*L^?'M^J'*^f^'"^'^TION only for Hospitals, InsfitutW Transients
or Recent Residents, and persons dying away froii home. '"nsients.
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
Hew long at
Place of Death ?
Days
fx>
^X'Mrvss
l^^oviWvK.iirit-
ri,ACK OF BrRIAI. <,R RFMOVAI. I DATHof n..... or RFMOVAI,
K
190'!
1
'^-^-^-A.O^vl 'H,...L<.
(Addres.s.. .\dX% ^Jl) 7v^ OU rU^v-tX^ .^^ ^
N. B. K%'ery item of Information should be cnrefullv suDnilerl ArR-I , , . . _ '
..a.» CAUSE OP DEATH .„ p,„i„ .,.„.. ,C U "J 't p*opeHr:,L*'.,''u,:i"''.;!h^'^^i=^7; , ^"^SICIANS .hou.d
«on, dyint away from home .houlil be tiven in ,»,ry Instance. ""••'"«•'• The Special Informsllo.i" fop per-
i^akiiM.
Wmt WRITE PLAINLY WITH UMrAniivir^ iKii.r i-Ljie> tt^ «. .n.-^.« • ii...... »
/>^^/^' /•>/<''/, LLu^Aa-v^
Lb.,
f\ A
190 \
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Registered J^o.
1 025
V^V^A^
-u Depuv
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Cettificate of 2»eatb
( la. S. StanDarJ> )
J? ^ J? Qj^
^^^/^n ^^ ^EATH: — County oiOcuy-o 0 AXX/ixo^CcCity of C)<X^k\; 1v<X.>v^^<l o.l
No, ^3.lo U[\xxtl
Ot/O.
St.; 10 Dist.;bct. 1 I ^t
and Jv,Qs 'V(A.'
FULL NAME
)
s !•: x
PERSONAL AND STATISTICAL PARTICULARS
'Month) (Djiy)
A^O.:. U NXLcLc.
1
Vw
\<^
XJL
rl%X.
(Year)
MEDICAL CERTIFICATE OF DEATH
date; ok dkath
Q,
IS
fDay)
(Year)
A ( ; V.
ll )v.,« U;
M.ivtln
Pit 1 .
SI\(.1,I-: MAKKIIvI)
wiix >\\j:i) ok i)!\-oKrj:i)
lUriti in vojj.-il <1( >ii>^!i;itioii)
HFRTHl'I.AOK
'St.itt or t'oiititrv^
NAMI-; «)l
I A thkr
lUKTHI'F.AlK
Ol- l-ATMHK
'Stale or I'oiiiiti v
MAIDKN NAM1-;
<>I MOTHKK
HIKTMIT.ArK
•>l- MOTIIKK
'St.itf or Coiuitrv)
(Month) J
rjp I IIHRHBV C1:kTIFV, That^r atteti.lc.l deceased from
A"^ Xt 190 H to .
that I last saw h ^^iA; alive on LXa.-
IS" iqoH
'^"Cl • ' 190 ;
and that death occurred, on the date stated above, at ( 0 • 2> 0
LIm. The CAlSlv ()]< I)I<:ATH was as folI„ws:
-C-^
<c
oK<x^aj 0 .\ <X <it /
^
.-^^
i:-
Ij
DIRATION )W,;-5 1 ;,«„;//;^
(SIGNED) .L<iA.^>cuvdL 0. ^i)
DCCr NATION
AV.\ /(/('(/ /;/ S",,->/ /'i ail, isi-i) ^^1 JV-,/;
A^v^c^
Days
Days
Hours
^ IQOH (A«ldress^ IHH^ 0^0^'.
Hours
M.D.
orf.LrJ'^'-J'^f^^'^'^T'ON ""'y f«r Hospitals, Inslifufions, Transients
or Recent Residents, and persons dying away frcn home. 'f-nsienrs,
1 A <;////.
/),n
Former or
Usual Residence
When was disease contracted.
If not at place of death ?
Hew lonq at
Place of Death?
Days
THi: AHOVH STATi:i) PKKSONAi. PAKTICri \KS \K1- THIK r. , rtiu- "77777! " . â– -
HKST OI-- MY KN<.WIJ.:i„-.K AM, nKMHF"''- ^^' '" '" ""-■^'^'^K '%,"''''A'' ' "^ ^HMoVAI, | I.ATJi^of M, k.a,. or RHM(,VAI.
(1
A-^CrO-O, r^;
^
i
T9o'(
'^' ^' J^very Item of information should be cnrefullv a..»»i:.,i A/>«r^! TTT """â– â– â– "â–
«»«to rAiicp: rkc nuTA-ru . """ "e cnreruiiy Huppliecl. A(jF. nhould be stated EXACTLY. PHYKiriAisia i. ...
state CAUSE OF DEATH m plain term*, that it may be properly clasiiified Th^ ••« • . ^"^^'^'ANS should
«on. dylnft away from home should be ftiven in .very instance '""'"*'*• ^^^ «»>«^'^'°' '"formation" for p,r-
«i^«»
^•y -A -i"
•'^ ■/•*'
..^â– ^.
f
^B^ WRITE Pi AINI V \A/ixu iiivirAniiu^ iiui# — . <t-i-iie> »«. m r^i-i^
i — ^ ITT IT n T I ^ ... . ...... 'vivtriaviiv >M ll«l« llll «ii3 I «3 *» r" C l~»
Hoard nf Ikulih -â– I" N'.i. is, 'i'f^'s^^^^ H&l* Co
/)((/(' Filvil, \
• *=» « f-u mviMi^ c. 1^ I ncv^V^KU
REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
l(c
wo\
Re^iNfcred JV7;.
1 0J^G
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of 2)eatb
( "CI. S. Stan^ar^ )
(^
A %
PLA^ ^P" DEATH: — County oiO lO^y^j 0 AyO^>VC^4^f Qty of Oclaa; 0 AXXaa^cia.^
e
ao
;v<lr
Dist.; bet. vA.'V^A
( '^ "'!^l",°*'^"r.®A^*''.r''°** .^.®^*'- RESIDENCE GIVE F*CTS*CALLCDrOR UNDER
r,^..,.. I T""- . r,^™ wwwF^i. nt^oiL/ciiv^E. dlVE F*CTS CALLED TOR UNDER SPECIAL I N ro R M ATin m •■\
DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD " STR Ee/'nD N UMBER )
v(h-*U) LlAM.y )
FULL NAME
> vx\. ^ vo... UA>CH;L^rLo
PERSONAL AND STATISTICAL PARTICULARS
Cni.nK ', A
i» \ ri". <>»• III R in
iLvvcU
M.jiith)
(Dav)
(Year)
MEDICAL CERTIFICATE OF DEATH
15...
(Day)
/go •
(Year)
Af, K
H?
5 Vi/»
M'nitfn
Da y.
SINf.I.K. MAKUIKI),
\vii)(»\y):i) <»K i>!\i »Rri;i>
'Write ill social <1( sii.Miatioii)
MIKTHI'L^CK
' '^tatf or t."Miiiitr\'
FA riii.K
DATK OF DKATH r\
(Month) K
I JJHRliHV CI:rTIFV, That I atten.lc.l (lecease«rfr(«i;
^^- 190'^ t.) CLv^Mrj. )..S:
190 H
[90
tliat Ilasrsawh :.' alive on VAAA-O^. â– j,p ;
and that .loath occurred, on the date stated above, at 2> ....
^J M. The CAUSH OF DIvATJI wis as follows:
^
&
e
X \>-VwOL/CXA-»
> \.K
HIKTin'f.ACF:
0( J-ATIIKK
(Stiti- or Country)
MA1I>)-.N NAM!
<H .MoTHKK
MIKTm'KACH
01 MnTlIFR
(Stiiti- or Countryl
OCCrPATlON OfVP
'XV L XcC\^ O V j (n-^XO- V »v
T 0 R \' X/KA/(in^.\.^
Mo)ilhs
Days
Hours
^
^
r)
C
^\L\d~
DrRATIOX - Years
/Mrs
X/Cr LU ) \j
*^ J -^^Ayyvux-^xq
(Signed)
^
n 4 'V V ;
190S (Ad.lrtss) 1 n dUUXv>^-^A.>L.o trxltv :\ f
Hours
M.D.
nr?p^„^?!!fl^, "^ir^'"^'^"'''^'^ •^"'y '"^ ""''P'^^'^' Institutions, Transients
or Recent Residents, and persons dying away from tiome. «"^«-.u^
f\f>ulfii in S'tn/ 1^1 ttn, i^f',> \ \ ' J>/m^
/>,.'i
* "V;. ■>?!!.* ^'''- ^'''^'''>-J» '"HRSONAI. I'XRTFilLAKS ARF TKrK To TU K
Hi:ST OI- MY KNo\VIj:I)<-,H .AM) in-IJl-F '
(liifornKiiit
> .■■■' >» I, 1 , 1 »i I /-, .1 .-s I /
.\A.A../^wO \Jj. 0 h^'CHQ^'VV v-O ^
Former or
Usual Residence
When was disease contracted,
If not %{ place of death ?
Hew long 9\
Place of Death ?
.. Days
\i
190 \
r:X''!';.'0^ '^"'"' ^'^ '^^^^"'^â– ^'' I DATK of I.rKi.K orKKMOVAI,
I i..^^r. ui- lu KIAI, OK RK>r()'
IXDlvKTAKFK V-XCLaX) V^-^t;:^
^VM..
.on. dyinft aw«y fro™, home should be tiven in .v.rt in»t.ll«. "'""""'• ^'" «"«'"' '"formation" f.r p.r-
â– i'j^BI^
;«*'?
r-;^
>-♦ /'
"^-^.l
"-'■nl..fH.....,„.-..N-o.K:»^.g^lU^,>Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I)(f/(' FiI(^(l,iLu<XYJ^ Up
7.96^^
JRegititcred JVo,
\ o;37
Deputy Health Officer
^No.
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of H)eatb
PLACE OF DEATH: — County oK'Ct'w 0 AXX^^vxcwco City of OaXat^ OivxX'^'c<^ <
M' Ua. .^ 11: (y^ Ixx '. - \- St.; — - -: Dist.; bet. -=r^ and
A IF DEATH OCCURS AWfV FROM USUAL R E S I DE NCE CI Vt FACTS CALLED FOR UNOtR "SPECIAL . N FO R MAT.n « ■• \
V .F DEATH OCCURRED .N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD oP STR E E^ AN D N U M B t «° '^ )
Cl C" C
FULL NAME
\AhXX\j:Xj. vAA^;X.4y|.v, . '
si;\
PERSONAL AND STATISTICAL PARTICULARS
'â– 1
DA'I'I-: nl- HIHTII
-Month)
ACH
y,\i.,
a
(Dav)
M. '),/>!'
(Vt-ar)
/)<7 1.
SINCI.K. MAKUn:i).
WIDOWKI) Ok IHVoKiKI)
'Write in social <l«sij/ii;itii>n)
HIKTHI'UAOK
(St.itt or (.'omiti \1
N\Mi-: Oi-
l-ATM i;r
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATM 1
L'Ll^^o is
(^<'"th) ij (Day)
I IJl'iRl-HV Cl-RTIFV, That I atten.lcl .kTcasod from
"^^' ^- TOO' to . LL\.^ra. \S., up\
(Year)
I9O '
^
that I last saw h alive on \X.
and that death occurred, on the date stated above, at
^â– '^ M. The CArSH Ol' DJCATIl Nvas as follows
1(/D
niKTUF'i.ACK
f)I" lATHKR
'State or Country)
MAIDKN NAMl--
01 MOTHKR
lUK Tin- LACK
ol" MOTUKR
'Stiite or CouTitry)
OCCri'ATlOX f}pU?
//ours
rCi
DIRATIOX 1 Years Mouths /)ays /
C()NTR IIU-TORV L'i>^.<ll^A„^..clv^..^
'>''RATI()X rears ^ Mouths Pays //ours
(SIGNED) LLv.\.n • (3.
Res id fit ill Sat/ /-'i ,1 1/, /.',', 1
- - - -y
lL
'^
M.D.
^^, '^ TQo' (Address) 1 '^ 5 JjLO..'\^.«
) 'I'li I
M.oith'
/)./
Tin- AHOVK STATi:i) PKKSOXAi, I'A K P KM' I,A KS \RK TKIF To TFIK
Hl-ST OF MY KNOWI.FDC.K AM) lU" AV.V '
(Infoiinaiit
ck^<j-v^<^^
^ \fMrcss
nr?.L^9*fi^J'^!r°"'^^"'''0'^ ""'> '""^ "o'ipitals, Insfjtutlis, Transients
or Recent Residents, and persons dying away from home. «"s«rniN,
fTrV-. %^ f. HoHlonq at
Isual Residence (lW>a.^v|c ' Plare of Death ? Days
Wtien Has disease contracted.
If not at place of death?
190
â– CV'-w.IUjXcL V^
n.ACK ..I- HIKIAI. OK K1.:moVAI. I DATFof HrniAr or KFM,,VAI.
INI ) !•: R 'l- A K F R J -Aa^^M^I^O-X' oLll r ' '^
^•■^'^'iress .n.5.' nXvA-'^rr^rr^rw c].l.
IN. B. '^^^••yjt/';" "^ •"f«;''"«t.on should be cnret'ully nupplled. AGE nhould be stated KXACTLY PHYSICIAN* u ..
«t«te CAUSE OF DEATH in plain term,, that it may be properly clarified The -S„T J 1 . ^"^^'^'^'^^ «»^«"«d
Ron. dyinft away from home should be liiven in .very instance ^'""""'**'- ^^^ «''*^^'"' '"formation" for p,r-
.^n:^
T
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
HomkI (J Ili:'lth I-' No ! r '^•sTiSRS^ USiV Co
/)((/(' Filed ^
^^ V.
.t lb.
VJO\
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
10^28
vu Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( U. S. StanOatO )
%
A T -A ^V
PLACE OF DEATH: — County of vJOyAV JA,(X-~> vcoft.ci.City of ^) lO^ywj J A,<X >^.X-v^ C
; 1 Dist.;bet.\I)^-CK>.d.c^icx.u. and UciLUXtt,
'No. lOl^VnU^lqt ,-.v..
(IF Dl
IF-
r OCATH OCCURS *W»V FROW US
DEATH OCCURRED IN A HOSP
St.; 1 Dist;bct.\l)^"^-<K>.d.c\.'CXLi and VQl
UAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION • \
•ITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AiIiId NUMBER. )
0
FULL NAME
.dA.l'k.
,£\.
ik
<x\.xx.
si;\
PERSONAL AND STATISTICAL PARTICULARS
^ I COI.OR
i).\ri-: «>i' I'.iK iM r\
-u-
\l \,
,r
w
Ai.K
..iith> \
\^ r.....
<I):iv)
1 A '.,.///'
L O... . . <.
MEDICAL CERTIFICATE OF DEATH
DATE OF nivXTlI /— ,
(Montli) \
^Vcai)
/'•n.
Sl\<.l.i:. MAkKIKD
WIDOUKI) (>K niVORCKI)
'Wiifcin "-iH i.tl (l( vi;Mi;iti<tn)
lUkTHIM.Ai'K
(St.itf ur «."<)Miiti V '
XAMK oi
FATM) k
Hik rm'!. ACK
OP lAriiKk
(State or c'uiiiili \
maii)i:n' NAMi;
OI- MOT I IKK
HiK'nn'i.Ari-:
OK motin':k
(Statf or CoviiUryi
' I go .
'I>.-iy) (Year)
I ni':RiaJV CI-RTIFV, That I aUcti.kMl .leccasea from
> ^ 190''^ to L:WvwriqL.....I..S iQoH
tliat I last saw h alive 011 l^l.v^..a_ 1'^ |oo
aiidLthat (Uatl) ocrurrcd, 011 the .late stated above, at ^
^M. The CArS^{ OF Dl-iAXH was as follows:
â– ^^UL'
â– V .i v_0
DIKATION }\'ars
CONTRinrTORY
Mouths Days ' o I /ours
I
A
DURATION Vrars
'^Y\Ar\^^'y\j
Mouths nav<
V ' Aj:iJ^-\
sJ^A
occri'A'iTox (Jj^
kVMilril III Sail f''iaiiri>fo
N-L'D^LU
( Signed ).L<x^rpuJLL<i \
U- \. â– â– â– n i i iQo ' ( A >i(i i-fssM ric--^ vt<:(.t V ^
?''^9'VJ'^^0'''^'^"''I0N only for Hospitals, InstUi
or Recent Residents, and persons dying away from home.
//ours
M.D.
>'i! I
}F.>„th'
n,n
rill-. AllOVK STATi:!) PKkSoXAl, I'.\ KTIC K I.A K S Akl- rkCK To THI-
HKST OK MY KNOW I,};i)C.K A.M) HKI.IKK
" a
Former or
Usual Residence
When was disease contracted,
If not at place of death?
How lonq ^\
Place of Death ?
ranslents,
Days
Oiifor tn.-int
a^^^\^\^\^
\ \.. O
J.
V ' • I > V IN I .A 1
[90
I'l.ACb: OK niRIAU OK KI.M..VAK j DATK of M,K,.vr. or RKMOVAI,
^^ I AJ-^vo 1.1 I,
(AddresH I 5 1^ jt^tt k-^ c ,. 1*.
N. B. F.very Item onnformatlon .houlcl be crefully supplied. AGE «houIcl be stated EXACTLY PrtYSICIAIMK u .^
lTn:^'\ "%''^^T" '" »*•»'" *— *»•«» '» -»> ^'e properly classified. The ••SpTcili InZIatlln^' C ^^r
sons dyinft away from home should be Itiven in every instance. â– nrormation for p.r-
I <
.*^'
^♦' i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
""""'"'" "^â– '1"' ' N'^ i^t-g^^H&PCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I'JO'i
Reglstet'ed J^o.
1029
Deputy Health umccr
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
PLACE OF DEATH: — County ofO CL/YV OAxXAxcc^Ct City of CJ <X/>\; 0 X.Ct/>x aui o <.
(No* JaJL^WC/A'V' (
(IF DEATH
IF DE*
OCCURS
St.
Dl
0
Dist.; bet.
• WAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER SPECIAL INFORMATION • \
ATM OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
[^
'\0
\ I
LdxAj<^_''..'.l
^
L^
and
lU
I.
s !•: \
DAIl". «)I- lUKTM
M'.K
PERSONAL AND STATISTICAL PARTICULARS
iK
M..tiih)
] 'rii ;
SIN'(,I.K, MAKUn-;i)
\\II)»»\V}-:i) OK IM\()kt,-KI)
iWiitriii >-orial dcsivMijitioii )
1%
iDiiv)
Months
MEDICAL CERTIFICATE OF DEATH
DATK OF DlvVTM
/
(Vfur)
II
Da 1 .
lUk TMIM.AOK
'St;itf or I'ounti V
NAMK Ol'
FA TMHR
niKTIlIM.AOK
<)I' lAlMKK
(St.'ttr or Coutitrv*
â– vvoaJL
(^
— ^c^q
(Month) \
I'l
(Day)
igo
(Year)
I IIHRl'HV CivRTlFV, That I atten.kMl ,lccease.r7roni
>-^-^^CL \'X 190' i to LLa-A^Q .i.'.\ igo .
that I last saw h ■'• alive on LA.s_ua '. ' t 190'.
aiul that death occurred, on the date stated ahove, at i . I L'
L . M. The CArSl- Ol" DI-ATII was as follows:
k
kJ-CYX^'
..'-..... X. '..... C//^rw\.v,\.^.^v,.v.<i t-^lv^ '
K.\J'^i.
DC RATION
CONTRIHUTORV
)'i'ars Mouths -^ Pavi
Ho lit
MAIDFN NAMK Q
OI- MOTHKK wY
iuktmi'i.acf;
o|- MoTHHK
(Slate or Country)
V^
duration
(Signed )
}'r(jrs
Q
AMo)iths O Pax^
Hou
rs
-(r\<wvcn
OCCUPATION \
h'cyiJrd III S.ni /'/,;;/,/>,â– ,> j )V-<mc ] .M.nilli- \\. f'hivs
I'ln-. AMOVK STA rKI) I'KKSONAI, 1V\ K TUT I,AKS AH I- TKVV Po ruF
ni;sT Ol- Mv KNOW i,i;i)r,i.: and i{kmi:i-
'O^ ^'^ i()0
ClAL INF
(Address)! C) 0 ?j
M.D.
Special information only for Hospitals, institutions, Transients,
or Recent Residents, and persons dying away from tiome.
Former or
Usual Residence
When was disease contracted,
If not at place of death?
flow lonq at
Place of Death ?
Days
( IiifoiinanI
*
?^..«i. %_,.lt.
(Address
aa^
v.<t'^ 3.1.
rr.ACK OF HIKTM 01? KKMoVAI, I DATFof M.hial or KFMOVAI
VnU ^1^^M^' I ^L^^-^J:^ '90'
INDICRTAKHK
(Addi.ss
Mil
(y)\
v<t<ivcnv d.^
N. »•— »;-Y*^riT«;i-^n"Jnni'M" •''7''' '"■* -"""f""*^ ""PpHecI. AGE should be stated EXACTLY. PHYSICIANS should
state CAlJSfc OF DEATH ..1 pla.n terms, that it may be properly classified. The '♦Special Information" for D.r-
sons dyinft away from home should be ftiven in every instance.
fstfj^tmk 'i'-JF'
write: plainly with unfading ink — this is a permanent becord
n.Mnlof HiMlth J No I .; *-5?~^ H& P Co REFER TO BACK OF CERTIFICATC FOR INSTRUCTIONS
])<(/(' Filed,
voot It l'JO\
Ocpuiy ('iOu^iLii. O-i'iiwj:''
Registered J^o,
1030
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
{ TU. S. StanDarO )
%
On
PLACE OF DEATH: — County of ^CLA\;OA>a/lvCLNiaCity of U/CUWj 0 ^CXyVL^<^cc
-No.3l\lK
f
(\
(
O-Vu-A K'iV<1.1\aA.,o..I' St.,
IF ocathAjccurs away iTrom usual res
iAAA..O..l'
Dist.; bet.
and
y^V
IF DEATH OCCURRED IN A HOSPITAL OR I
FULL NAME
ilDENCEGIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
NSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
/
si:x
DATK or I'.IK'IH
AC. K
PERSONAL AND STATISTICAL PARTICULARS
I COLOR
>
(WJJ^
h
I Month
/VV
U
'-7
)V,/,
I \
(l)av)
Minilhs
(Year)
Pay:
SINCl.i:. MAKKIMI).
WIDOW KI> OK DIVoKiKI)
(Write in scxMal desijf nation)
I$IKTm'I.ACK
'St.iti- or CVmntrv)
NAMi: 01
I-' A r 1 11; R
RIKTm'F.ACK
Ol' I-Al'UKR
(State or Country)
MAIDHN NAMK
01 MOTHKK
lUKTJnM.ACK
Ol" MO'rnKK
(State or Conntryl
vvo.
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATH
Ll
(Month) \
(Day)
/go ,
(Year)
. 1 IIKRKBV CivRTIFV, That I attended deceased from
M.V^sA,^^.. !i. 190'! to ..LvL^s..^ 1.1.. uyo\
that I last saw h •• . alive on Lv^.^vCl ^ \
and that death occurred, on the date stated above, at
sA. M. The CAISR OF Dl-ATII was as follows:
It/)
1 1 t.
L
Dl'R.ATION Years
CONTRIIUTORY
Months
Days
Hours
T'
X
occrrATiON J?
O
X.C4vcrO
-4
Dl'RATION
(SIGNED)
}'iars sMouths
Pays
a>...
ail
IC)0
(
(XW:)
Ad<iress) at VnL
Special Information only for Hospitals
or Recent Residents, and persons dying awdy from home.
, Instifutlons,
//ours
M.D.
4xt.
Transients,
,ii
Former or 1 \
Usual Residence U A.-O.D..
'^-0
Rfsidrd ill Si7 H I'l iiiii iM'ii
) 'tUX I .
1 Months ' *.
/J,n
How long at ,
PJareof Death? 1 ^. Days
When was disease contracted,
If not at place of death?
THI. AHOVK STA'n:D I'KKSOXAI. I'AKTICn.AKS A K K TKIK lO TIFK
iiKST Ol" Mv k.n<»wm:d(".k and HHMHF
(IiifoiniaTit
\\ \
(^
A.A-CX-^'V^v.tx^
l'I,ACK Ol- BIRIAI, OK KI:M(»VAI.
rN'DKRTAKKK Jc . \L. 0 <xLL<X^kX' ..
Address ^ aO - 5 1%. 4*
DATKof HiRrAi. or RKMOVAI,
L'Lcvq I'.,
TQO
M. B. F.vepy item of information should be cnrelfully Kiipplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information*' for p«p-
Rons dyin^ away from home should be j^iven in every instance.
mm
r
ii^i
Hnai.l of Hialth - V N(V i^ t^'^l^^^ USt J' Co
•vi_iie> ic* ii t3 r emii A ivi c ivi *T' iaxrr*f\tir\
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
lUi
((' /^V/fv/, IJ^a-^axV-aA^ f^ ^'^^
^>(9H
Registerecl JVo,
103 1
cMrLwo Aju
\>^ Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Death
( xa. S. 5tan^ar^ )
PLACE OF DEATH: — County ofCVO/ru J /vcv>vcuiccCity of CI/CL/Tu 0 /VC^^vcA^^ac
No. 1 C)C)1 ll->\.v.,c--^
^.
St.; i Dist.; bct«
o
and
(IF DCATH OCCURS AWAY FROM USUAL
IF DEATH OCCURRED IN A HOSPITAL
RESIDENCE GIVE FACTS CALLED FOR UNBER SPECIAL INFORMATION
OR INSTITUTION GIVE ITS NAME INSTEAD^JOF STREET AND NUMBER.
)
a.Aj-voi.1 )
FULL NAME
11
^ c- 1 V.
K
.t...--^
SHN
PERSONAL AND STATISTICAL PARTICULARS
'iLo^lx
UJyVVA.tjL
DA 11-: nl- HI KIM
Ai.i-:
t
C ^
J v.;
II.
10
Dav)
}f.>iitfn
/I HA..
(Year)
Pars
SIN'C.I.K. MAKUIHD
WIDdWKI) <»K I)IVi)KrKI)
'Uiitiiu "iiKMal <Usijrnatioii)
HIK rni'LACK
(Statf or (."MUiitivl
1,
ojxaaxxI
'VCU^XClA.
N\MK OI
I- A Til l.K
lUKTllI'I.ArH
Ol- » AIMKK
(Slat< or i'<iiiiitT \
MAII»i:n NAMl
<)!• MOTHF.K
niK rni'LAOH
Ol- MOTIIKK
(Statr or Coiiiitrv)
(XXrPATlON
on
^ /vex. ^'^<UL
0
MEDICAL CERTIFICATE OF DEATH
DATH t)l- DKATII r\
UwA.V/Q
(Month) K
IS.,
(Day)
7pO I
(Year)
I HICRICRV CIvRTIFV, That I attended deceased from
^^.^A^"v k<: 190 0 to iJsA.A,,/n )..^. 190H
that I last saw h-^ y> . aUve on LXa^v^CL- ' -^ igo 1
and that death occnrred, on the date stated al)Ove, at
_ M. The CAI'SK OF DIvATII was as follows:
.rfij'^-.fr-Wu VAw^v,<\Jk^<>r-^,A^ .:>... 0:W... J^
/O'V^rCU-yv
ev-^-f ^ •
DIRATION S Yt-ars Mouths,
CONTRIHUTORV La/vaJ^
Days Hours
V<yAA^...01r.....3wAA,S^.;.!
I )r RAT ION S Years Months Pays Hours
(Signed) 0--Uj Ja.,.^hi^;i. m.d.
\Xv.uq. .15. iQo'i (Address) 3X^ JULQJvaa^^ lit.
SPECIAL INFORMATION only for Hospitdis, institutions, Transients,
or Recent Residents, and persons dying away from home.
Rf sided in Sap I'l tiiii iu'it v> )'roi>
M.nlih,
/',/!.-
THK AIU)VK STATI-.I) I'KRSONAI, I'AKTirn.AKS AKK TRl K TO TIIH
HKST Ol" MY KNOWI.KIX'.H AND IIKMICK
(7. (^
(Informant
-V.Mir^s OOo
frixA^a c-^mjLV-o
a..
Former or
Usual Residence
Wlien was disease contracted,
if not at place of deatfi?
Hew long at
Place of Death ?
.. Days
PLACE OF UrRIAI, OR RKMOVAI, I DATK of III KIAI. or RliMOVAI,
i\KV\xvL /^OS \l 'L(r^AX<xV Lls^^:,
N« B. Bvery item of informotion should be cnrefuily supplied. AGE should he stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for psr-
Rons dyin^ away from home should be ftiven in every instance.
â– 'H^i^syt
'jmb..
. •• v« Ba«l^ir«lki<
1 i
t i
ii
WRITE PLAINLY WIIM UI>I^MUllNVJ mr\ — inio lo m
MnM.infii.aitJ, FNo Ki^-gSJ^H&l'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Ihtfr AV/rr/, (Xu..OL^^ |(o JOCi
lieglatered Jfo,
1 Q'Vl
<j^^.^r\..^<,A^
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Cevtificate of Beatb
( xa. S. Stan^arD )
J? ^ J ^ •
PLACE OF DEATH: — County of ^ CCo^ J-^xxXz-v^^cuirCcCity ofO/(V>^ JXXXAve.A_>^c.<.
^No.
b\l \l KOL<i.Cr^v St; I Dist; bctA. a.A.A u ^ and â– JA..U...)
/ \r Dt*TH occults AWAY FROM USUAL R E S I D E N C E Gl V E FACTS CALLED FOR UNDER "spCCIAL INFORMATION ' "\
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STiicET AND NUMBER. /
â– ^\
FULL NAME
I) e
PERSONAL AND STATISTICAL PARTICULARS
s):\ (K\ \ I coi.oK
"J'
1
DATl". «)1' III K Til
yW^^
\
Mouth) K
AC, 1-:
) V-,;
(Dav)
Mniithy
I
(Vcar)
Oti \s
SI\<; l.K, MAKKII.l)
\VII>t)\VKI> <»K DIVOKrHI)
iW'ritt in sot'ial dcsijj^tuitioti)
lUKTMIM.Ai'K
(Statr i>r I'miiitrv*
NAM1-: (H-
FATin.K
RIKTmM.A^H
OI" lAPHHK
(Stitt«' or C'oiiiit ry*
MAII)I:n NAM1-;
<)1- MOTHKK
inKTHl'I.ACH
oi" MOTHKK
(SiaU' or Country)
OCCrPATION
vcc^^.^^
'>\.0„ .'
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATII
\
(Month)
(Day)
igo
(Year)
I H!<:RIUJV CICRTIFV, That I attended (Icoeased from
LLvA^^ IH 190'', t(i . . AAa«a^....1H loo'i
that 1 last saw li •: alive on LcV\,\^A:y. W up .
and that deatli occurred, on the date stated above, at O
â– J M The CATSIC OI- Dl'ATI! was as follows:
O nf\yCK,y^^^.t,^^ t . s.
DT RATION )'ears
CONTRIIUTORV
Mo}itln
Days
Hours
\^oJLkJ^ ' w \ V '_ c
Di; RATION
(SIGNED)
/ C U / J
Months
'0
\X^
LLv.^q W i()o'. (Address) .iS.5.^.
Cf
Days Hours
O^bJr:. M.D.
SPECTAL information only for Hos;)itals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
Resiiifif in S(in /'i itm i<ri^
) I'll I
:/,»////.<
/)<;i.
rin-: ahovk stati;i) i'kksonai. pAKTicri.AKs ari-: tkif: to tiif:
nF:sr of my knowi.kix; f: and lua.iKF
Pa
(Informant w^CV
f Xd.lrcss
<X<I. ^ ,
â– \
Former or
Usual Residence
When was disease contracted.
If not at place of death?
How long at
Place of Death?
Days
PI.ACH of BI'RIAL ok KICMOVAI, I DATF: of m-KiAr. or RKMOVAI,
'V^A_ I
190
r\(Mrc«s
n).0..5. yX(r^l/c\;\^....Li»A,>^
.>^.
N. B. Rvery item o? information should be cnrefully Rupplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information'* for p«p-
sons dyinft away from home should be ^Iven in mvcry instance.
xAiotTc Di AiiMi V lA/iTu I iMrAniMr^ iMK xu I c: I c: a Dr BMAMP NT orrtr^nn
n..;ii.l .r il.Mlth- I No u*^^fc5H&l'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I)n/(^ F//fV/, CL^OL^^ l(0 ie9^i
oUi-vx^^ d^x^>-u Deputy Health Officer
Be^Lstcred J\'*o,
1 083
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
"a. S. Stan^ar^ )
PLACE OF DEATH: — County ofOxX^ru 0 AXXwcuiCij City ofO<X/-r\; vJXOl/>v<<^v.nLC.o
f No. Uiv^LdAJy^
xxi UO O^Y^tccL St*; "
(\T Dt»TH OCCURS AWAVifROM USUAL R E S I D E NC C G I V C FACTS CALLED TOR UNDER "SPECIAL I N FOR M ATIO N •' "\
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
Dist.; bet.
and
)
FULL NAME
JLC^aL^.'..
SKX
PERSONAL AND STATISTICAL PARTICULARS
fv I COI.OR \
^
DATi: <)|- lUKTH
Monih)
i
V
<Xjl
Q ,-
\f. K
I
) â– /â– </
H
(I)av)
M, mills
ir)
MEDICAL CERTIFICATE OF DEATH
DATE OJ" DKATII
15-
(I)iiy)
(Mouth) a"
(Year)
n,i 1 .V
SINi.I.K MAKklKI)
WIDOWKI) OK I)I\ <)K( i:i)
(Write ill s«Hi;il (|( si>.'ii.it ion)
m
HiK rni'i.ACH
'State or *_"ountr\'
NAMK Ol
KATHKR
mkTMPI.ArK
<>l" I ATHKR
I Stale or Con tit ry)
MAIDHN NAMK /7\
Ul- MOTHKK L
I nrCRHBV ClvRTIFV, That I attcndcMl (UHoased from
\>J. Q^S 190 't to . UwA^A^ IS. 190 H
tliat T last saw h i., . . . alive on LA-'^^~0^ VS igo i
and that death occurred, on the date stated above, at
AX M. The CArSH OF DIvATII was as follows:
C3./C/Ow>JLcjfc .vl..r:C.V.-.^:..\'
kA^V^X
as 1 01 lows :
X <5^Jw^V\>-v.':>. v.Q.
or RATION
" } 'ears
O-^
HIKTHI'I.ACK
<>1- MOTHKK
(State or Count rv)
oJLu
Mouths S Days
Hours
OCCrPATION
Resided ill Sav /> mi, isro I )V'<7/> \ Af>>>/l/is ~
CONTRIIUrrORY
DURATION Q^^'''^''^ Months 1 5^ nay.\
(SIGNED) h) . y Gu<xJlA\.X^
Vit^^Or \^ iQO^ (Address) UJXwdvt-y
SPECIAL Information only for Hospitals, Institutions, Transients
or Recent Residents, and persons dying away from home. '
Former or
Usual Residence
XA
Hours
M.D.
Pa
TJIH AHOVK STATi;i) PKKSONAI, TAR iUT I.AKS A K l-, TKrK To TIIK
HhST oi- Mv kno\vij:i)«-.k AND ni':Mi:F
Hiifoi niaut
(A (1(1 res
1 ^0 MOM-<xcUv a^/ ']\ Place of Vath ? 1 ^> ^ y .. p^yj
When was disease contracted, x 1 0 I) 1 * i)
If not at place of death ? oX) Jr\)L<k.cJL 0:\r CU-coJk,
I^'ACK OK niKIAI, OK KKMOVAI. I DATK of Hiriai. or RKMOVAI,
c\r>v I vJv\A^qi lb 190H
KNDKKTAKKR
(Athlress
N. B. Every item of Information should be cnrefuliy Hupplled. AGE should be stated fsXACTLY. PHY8ICIAN8 should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The ♦'Special Information" fer psp.
sons dyinft away from home should be given in •\9ry instance.
(J
r
•I
tl
WmMLi .ItBSrf'
ki r» iki««> i^i^^«^^^
1
i
WHI I t. KLMIINLT Wl I n Ul^irMUmVai ll^r\ imo la #n r-cnrnmi^ci^ i nuwwrik^
REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
Hoard uf Utalth— KNo it. >*i^^) 1J& P Co
Thifo Filed , iJ..XAyOi/\^x.^
Ho lOO'i
Reglsteved J^o.
1034
.-CrV^^-^VwO
, D e p -i.e./. He a It h.. Off! c c r
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Cevtiffcatc of H)eatb
( Ta. S. StanC>arC> )
PLACE OF DEATH: — County of Ci Cn^^^r^-^ \^cx
City of O crvx.<rwv/cx,'
(No.
St.;
Dist.; bet.
"and
(IF OCATH OCCURS AWAY FROM USUAL RESIDENCE CIVC FACTS CALLED FOR UNDER "SPECIAL INFORMATION" 'N
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
yj KJL6^sJLKj.,y^Jy\yOj
PERSONAL AND STATISTICAL PARTICULARS
sKx ny\
'
DATK OF lUKTM
AC.K
L
COI.OR
.VW
\JL
Month)
n 0
^
IS
(I>av)
yfnufhs
(Year)
Pa \s
SINCI.K. MAKKIKl).
WIIXAVKI) OK DIVOKC'KI) X
(\\'ritt'in s(K"ial (W-sivtiation) i . ^
HIR TMPI.ACK
(Stritf or Countrv^
NAMF. or
FATHKK
BIRTH PI.ACH
OF FATHKR
(State or Country)
MAn)F:N namf:
OF MOTUHR
inKTuri.ACF;
t)F" mothf:r
(state or Cotmtrv)
Lv \.cC^^
IX\ •> >vrL
'>vev^'
MEDICAL CERTIFICATE OF DEATH
DATF: OI- Dl-.ATM
I..5
(Day)
(Montfh)
7ooH
(Year
I in':Ri:iiV CICRTIFV, That I attended (Iccoascd from
— to 190 ~"~~
190 —
that I last saw h ".:- alive on
190
and that death occurred, on the date stated al)<)ve, at
:^~j M. The ^^'-"^K OF I)I<:ATri was as foIIi)ws:
ab-Jia/vA' d.^x^Ju^/vA^ ^Va^ix/^vvA-c
...\j../QJLsJ^^V^JL.O./A.:
. ' 1
I
I
DURATION Yeats
CONTRIBUTORY
Months
Days
Hours
DURATION
occ
U PAT ION (Jplf
f)
Rfsidfd ill Sail I'l ,1 in 1 m n
(SIG
CL
^TION , Years
NED) J. \ a<J
Mouths
Pays Hours
M.D.
\.\^a l!.^ u)0 'i (A.ldress) O (rYvcr>-wA<<cc V^^C^X ).
cIalTn
SPECfAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from liome.
)■/•(/;
Ar»ii//is
n<n
THi: AKOVK STA if:!) PKKSONAI, P A K IICF I.ARS ARF: TR I'K TO THF:
HHIST OF MY K NOW I.i;i)< , K AM) MFI.IliK
(Inforntant
oio. Iro. CcwjL ... .^AA^vt
(^ p
SJL'^^JL^
T\^-iLV.t\A.
i
Former or
Usual Residence
Wlien was disease contracted.
If not at place of deatli?
Hew long at
Place of Deatli? Days
190 V
PI.ACK OK lURIAI. OK KHMOVAI, | DATK of IJlRlAL or KKMOVAI
cNDi-KTAKHR V yy\jL^H:Lft^ ^ ajLaJk^
(Addres.s ^..^...l...Al..r\A^lAA^tn.\.....D.,t.
'^' **• Rvery Item of information should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special information'' for per-
sons dyinft away from home should be |t«ven in every instance.
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
»
n...r<l..f iic.ui. » No i.^*^^i)i{&pro REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
Ihdo Filrd,
.Ait It..
7^i9H
Registered JSTo. 1 0o5
u..
t
II;!.''"
;.ealllb...aiSir - -
DEPARTMENT ofr PUBLIC HEALTH=City and County of San Francisco
Certittcate of H)eatb
( in. S. StaiiOart )
PLACE OF DEATH: — County of^^Oyvu 0AxX/>vCMi<>0 City of ^OOyvu OA/Cu>vq.c^ccj
No. T H 1
Q^V
Lv.<UlOv
1
St4 ^ Dist.;bct. Ohx^V^u
and
%A
f ir DC*TH OCCURS *WAV FROM USUAL R E S I D E N C E G I VC FACTS CALLED FOR U N DE 1^ " S PEC I AL INFORMATION" \
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD 0« STREET AND NUMBER. )
Oj^y\.<x. )
FULL NAME
itx
rx/.yxj..
si;\
PERSONAL AND STATISTICAL PARTICULARS
COI.OR
U)ivoLi
DA'IK <»»• lUK in
AC.K
%
I Month)
(I)av)
(Year)
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH /O
vjIaa^q
(Month) K
lb.
(Day)
(Year)
) I'O I .
5:
M.intfis
S
Da I .V
HI\C.I,i:. MAKKIKD.
WlDnWHD OK I)F\()R(KI)
(Write in scH-iri! ilt>iij.'ii.'if ion)
HFKrHIM.AOK
(Statr or Country)
NAM1-; OF-
FATIFHR
RIRTFlPI.AlK
OF- F-ATHKR
(State or Country
MAFDl^N NAMH
OF MOTHKR
niRTMPI.ACK
OF- MoTFn':K
(State or Country)
'X
I HRRHBY CKRTIFY, That I attended deceased from
vXu^Ol i^- 190 '( to LLv.-i.x3u. .1.(0 190 H
that I last saw h -.t ^ v\ alive on LAa^v.-q 1 V jgo '4
and that death occurred, on the date stated above, at ?) XO.
0 AL The CAUSrC OF DKATH was as follows:
DURATION Years
CONTRIIiUTORV
OCCri'ATFoN
Mouihs 1 Days
Hours
duration
(Signed)
Years
Mouths
f^ays Hours
Rfsidfd ill St\ti I'muiisi-o O Yrai .< -^"^ Months i
190^1 (Address) 2)S I 3a.vUjUv Bl
M.D.
?^^9'?i^J'^r°"'^^'^'ON only for Hospitals, institutions, Transients,
or Recent Residents, and persons dying away from home.
Former or
Usual Residence
i\i\.
When was disease contracted,
If not at place of death?
ftew long at
Place of Death? Days
' "l;,^!ii*^ ^' ^'•'^'•■f:i> f'krsonaf. i'artfcii.aks akk trik to tuf
llhST OF MY KNOWI.KDC.K AND IJFMKF
(Informant \i y\yC^AjLcX Cd . J (iAhVA V
^Address
:i4i
UXlAAyUAj dl
pi.^E of; bfriai. or rf:movai.
l^-^'I^of BiRiAL or REMOVAI,
^ T90H
UXDERTAKKR \ Vj . U \w,<n^yVLVV ^^"^
(Address
""' "'~rtaVe*'cl7sF*Ap nTrxH"."*"?'** **" ^"-^^^''^ supplied. AGE should be stated EXACTLY. PHYSICIAN
-inl H 7 - OF DEATH m pla.n term,, that it may be properly claimed. The "Special Information-
sons dying away from home should be ftiven in every instance. mat.on
8 should
for per-
I
d . .Mi
\f
^'1
■«
•1
!||
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
H«Kir(l of llcjilth-F No. m T^-^Jw^ H& I' Co
REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
/)((/(' Filed ,
ij[ 190'\
Registered JVo,
10*16
duJv-u Peputy Hearth Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Death
( 'Q. S. StanOarD )
PLACE OF DEATH: — County of
-P
City of UuXOL/WOj CJ^CUXA'vu CV.Qv
(No.
St
Dist.; bet.
and
(IF DEATH OCCUHS *W»V FROM USUAL R C S I D E NC C G I VC FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
)
FULL NAME
Vj /CLfov^ok LU
\JJ\.^r\j
PERSONAL AND STATISTICAL PARTICULARS
s};\
riojui
COI.OR
IjO'I^u
DA IK o|- HIKTH
AC.K
/
MEDICAL CERTIFICATE OF DEATH
DATK OF I)I:aTH ,0 h
.JL .10..
(Day)
r\A.v
(Monlh)
(Year)
/
I Month)
!''â– (( >
tl):ivl
.^/.mt/is /
(Year)
Am A
SINC. I,K \!AKKIi:i)
WIIXiUKI) OK I)I\( >kr)-:i)
(Writr in M)ri;il <l(sii.rnittiim)
lUKTHPLAOK
'St.it' or (."oiiiitr\'>
NAMI-: OI
KATIIKK
lUK'llll'I.ArK
<)»•• I-AIUHR
I state or C'oiintrv)
MAIDHN NAMK
<>!• MOTHKK
inKTHI'[,ACH
<U" MOTHKK
(State or Cojuitrvl
I HHKIUiV ClvRTIFV, That I attended deceased from
— to
190
that I last saw h ~ — alive on
190
T90
an<l that death occurred, on the date stated above, at
M. The CAUSH ()!• DI-ATII was as follows
DIRATION Years Months Days Hours
CONTRIIU'TORY
DURATION
(Signed )
)V</rj Jfont/is
IqO
(
Address) LL . a.
oceri'ATioN (Vu
f\f>iiir(f ill S(jn ridih isi'o
5 'I'ti I .
Ar,uif//s
Dcvs
Special Information only for Hospitals, Institutions.iranslenls.
or Recent Residents, and persons dying away from home.
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How long at
Place of Death? Days
rnr: auovic statkd pkksonal rAKTioii.AKS akk tkik to thk
hhst oi- MY k\o\vm:i)ok and hhi.ihi--
a. IT)
(I
r\rW«:^SS
<XV-vo
;^M.ACE OF buriai, or kkmovai.
ini)f:rtakf:r
^â– \<l<lrcss
DATK of BiRiAL or REMOVAI,
JX ... 190H
'^l
u. i , a
-jl\\X
^' ^' rtrJcArsF^Ap^nPrTS""*"?'** ^" ^"-*f""> «uPP'5ed. AGE should be «tated EXACTLY. PHYSICIANS should
«inl H • . c I '" **/"'" '*'•''"•' •^^^^ '' '""y *"" properly classified. The "Special Information" far per-
sons dyinft away from home nhouid be ftiven in every instance. ^
L '^:
-f4 it
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Hnjtnl (.f Utrtlth-I" No. i«; S-F^J^^H&p Co
0 jT
ow(rvAA^
10 0\
Deputy Health Officer
Registered J^o,
1032
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Death
( "Ul. 5. StanDarD )
fU
'Na VC
PLACE OF DEATH: — County of 0/CL"r\; O^uX/W^cuic.c City of C)/CL^.; 0 A^Oy^x^M^^^x
\X
()0(H.W.to_l:.St.:
Dist.: bct«
and
/ IF Dt*TH OCCURS AWAV FROM lllSUAL R E S I D E NC E Gl V E FACTS CALLCD FOR UNDER "SPECIAL INFORMATION â– \
\ IF DEATH OCCUrt>«CD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
:Yv-rvsJ.
DATi: OI lUK 111
PERSONAL AND STATISTICAL PARTICULARS
<3^
„<x.
I
J JLAr
I Month)
(Day)
(Year)
MEDICAL CERTIFICATE OF DEATH
DATK OI- DKATH
(Day)
(Month)
(Year)
ACK
I ^ Win < ^ Months y. \
Da vs
SIN(.I.i:. MAKUIKI)
uii><)\\i-:i) OK i)i\< »Kv i:i)
'Writt in Mninl dcsij^nation)
lUKTFIlM.AOK
'State or Country^
NAM!. OI
i-atiii:k
HlRTMPI.At'K
<)»•• 1-ATHKK
(State or Conntrvi
MAIDKN KAMI,
ni- MOTHKK
lUKTHPI.ACK
OI- MOTMKR
(state or Country)
I HPtRI'HV Cl-RTIFV, That I attended deceased from
LL^cAXi l.X I90M to vU.AxCL..l.b..
that I last saw h ^^i-^v alive on
1 niicui I
I90H
l.i.
190
'i
and that death occurred, on the date stated above, at IX-^"^
4I M. The CArSB OT DICATII was as follows:
\J -AAJL^VVV^'V^XXAA^
DIRATION Years
CONTRIBUTORY
Mouths
Days
Hours
OCCri'ATlON
%
"JLo^
£) 0-<-C^lj4.A.VM.iUi'
Resitird in Stiti /'> am /wi)
)'f til V 1 l/.'^////N
DURATION
.NED) UJ rrru \l7\
(SIGI
}'ears
cyy\j
^^ 190 H. (Addresf
Months
Pays
Hours
M.D.
SPECIAL INFORMATIO . .
or Recent Residents, and persons dying away from home.
Lvss) Ld:uX.^^.Q m CKO.|.vt.
N only for Htkpitals, Institutions, Transients,
Former or
Usual Residence ^
hiiv
THK AHOVK STATi:i) I'KKSONAI. I'AK Tlcr I.ARS A K F. TRVF To THF
iihST OI- Mv kno\vm:i)<-. H AM) nHi.ri:i-
(Informant LU rVVA.) . \l /\. Os^VAATA^^CA^
(Address
<X-^yAyCL VX) .
Wfien was disease
if not at place of death ?
contractei^
Hew lonq at
^'^ Place of Death? H Days
I'LACH OF m-RlAT, OR RKMoVAI, I)ATi;,of lU r.ai. or KKMOVAI,
^-M/lfVAOA/S^^CC-CV-^-x- I ^^'^^^^^^^^^^ \% I90H
^Ad.lress !i.^.'l.l....>4^^
^' "■TtaVe^^Ji^irsF^Ap nTri'r •**7''' **" ^"'•«f""y supplied. AGE should be stated EXACTLY. PHYSICIANS should
!«^1^^ . OF DEATH in pla.n term*, that it may be properly classified. The ''Special Information" for dt-
sons dyinft away from home should be ftiven in every instance.
- '-
mi
f'n'
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
Hoard of IlfiiUh- »• No. !S *^E^ H*^!' Co
I)((fe Filed f
A^Xl^ 11
100 "A
Registered J^o,
1 0.'^8
Deputy HeMvh Officer
DEPARTMENT OF PUBLIC IIEALTH=City and County of San Francisco
Certificate of Beatb
( Xa. S. StaiiDarD )
— County of O/CUvu 0 /L-CL^v^^A^c^City of CjKX^Vu 0 X^<X/>ax:.^s.<l-C c
PLACE OF DEATH:
(No.
Sos'iiiuJ^
\X^\)
St.
\
Dist.; bct.^' OJi.rLvw.ql^ ^> \. and
A.^^>
CI
(ir Ot*TH OCCURS AWAY FROM USUAL R E S I DE NC E Gl VE FACTS CALLED FOR UNDER "SPBtlAL I N FOR M ATIOH '• \
IF DtATM OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STRt-ET AND NUMBER. /
ai
li
(<)
FULL NAME
'\Xkjy\j. 0 <X/mj \Ltv.A,jL:y\:
SKX
DAT!-: oi- lUK rn
ACK
PERSONAL AND STATISTICAL PARTICULARS
COL
(5;^
""Vli^.-
'SA
<Mo!ithl
'"^ I JV,/;,v
\^
1.
(I)iiv)
Mouths
(Year)
Da r.
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH ^
(Day)
I go
(Year)
SINC.l.K. MAKklHI)
\vii)<)\yKn OK nivoRiKi)
'Uritt'jn S(x-ial «Usivr nation)
niKTMFI.AOK
'State- or Country I
I
i
i:
y'
NAMH OF
FATUKR
HIRTHI'LACK
f)l" lATHKR
(Statf or Country^
MAIDKN NAMK
o»- MOTHKR
lURTin'LACK
OF MOTHKR
(State or Countrj)
VAw/W^CX^
(Month) J
I IIHRHRY CICRTIFV, That I attended deceased from
— to :â–
190-——
that I last saw h •• - alive on
190
190
and that death occurred, on the date stated above, at I ?v
AJ M. The CArSR OKDJ'ATH was as follows:
-Q.^
— ^"^ \ I
r
DURATION Years ^ Mouths Days Hours
CONTR IBUTOR Y
0^
vl AJl
w
i.
'*
>JkjUL
vtx
duration
(Signed)
Years
AlfoHi/lS
Resided lit Sav /'i nii, isr,} I ( )',-,i i ^
Days
Hours
^AJ.<^. M.D.
^>A/q, 1^ 190'^ (Address) (pOb d^Ottuy. dl
PP
f^^^'fi'-J'^f^^'^'^'T'ON only for Hospitals, Institutions, Transients
or Recent Residents, and persons dying away from home.
v../////.
/',n
Former or
Isuai Residence
When was disease contracted.
If not at place of death?
How long at
Place of Death ?
Days
''""\k^J^-r*y.^'■«'.^ '•"'■'" »"»^K^'>NAI, I'AKTU ri.AKS AKI! TKIK To TH H
HhSr OF ^V KNO\VI,HI)<;kaNI) HFI.IKF
(Informant
(Aria
ress
10b
(J
(Ow/Cx^^
p
FI.ACE OF-^BIRIAI, OR RKMOVAI. DATK of Ht-RiAi, or REMOVAI.
INDERTAKKR oL/L<OCr>-
/
7
^ t
K ^
HII
<;â–
I90H
(Address 1 0 ^
JCrVk d^^c^
rH
^' B* Every item of Infor
state CAUSE OF DE
«on« dying away from
^ri-'r. •*'7'.** ^^ '^-'••^"'•y supplied. AGE should be stated EXACTLY. PHYSICIANS shauld
EATH m pla.n term., that it may be properly classified. The "Special Information" far a.r.
om home should be given in •very instance.
♦ ■1
r
> %.i
>
d
1 1 'I
m
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I'.o.M.l ',f n< :i!t!i- I- No. K t?^'^-'^- I'mS; J' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/)(f/(' Filed J
H IDO'i
Beglstcred J\^().
1 0*59
M Dcp'.-, •■'■■„, Officer
DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco
Ccvtificate of Beatb
( tl. S. StanC»arD )
i Oil) -^ ^
PLACE OF DEATH: — County ofv.'/Ou^x^ 0> v<X. >^c^ui^City ofCj/OLA^ ^ KXXyy\.Al^<y<^<:^i)
No.
l^'i
OAy~w<X'
St.; ^ Dist.; bet.
^
md X C^xAj
(IF DCATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" "X
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
sj;\
PERSONAL AND STATISTICAL PARTICULARS
rjn ji I COLOR
*\\i{ oi iMK 111 jr\
M-.ntli)
A<.!-;
H^ r,.,„, S
(I):i\l
1 /,.;////<
(Vf.'tr)
Ay^w^cLcueJo
MEDICAL CERTIFICATE OF DEATH
DATK oi- I)i:.\TII
It.
XL
/>,n^
-^iNt .1.1-: M \K K n:i)
\\ IDi >\\l-l) OK DIXoRiKI)
^^'' it'- in ' <li -i;.MMtiiPii I
lUK IHI'I.ACK
'St.itL- or Coll lit r V
1 \ IIN-.K
lUKTIlIM, ACK
o)- 1 A I' III-: 1<
MAIDIIX NAMi:
Ol- Mo'lin;K
Mikinpl.Aci-;
Ol" Mothi;k
'•^t.it. ■,] Co\intrv)
'Hcr]'\-ii(»N(gy) ^
RfFiilfif in Still I'l ,111. i^rt) A
a)ay) (Year)
I IN<:ki:HY CKRTIFV, That I attcMi.k-.l .IcHX-ased Tr^n
3-'^ 190H to. La-\a/CL 1.5^ iQoH
that I last saw h^'i alive on LLwQ ^ iS 190 H
.111(1 that (kalh occurred, on the dale stated above, at
M. The CATSI': Ol- Dl-ATH uas as follows:
DCR.ATION Years Months Days Hours
^fonf/^s /)ays Hours
1 M K .A 1 1 () .\ ; , ars . Mon ilis Days Hours
f)rRATI()N Vcars
(Signed) lU. Li. .L) c^^.^xJ\X^^lu m.d.
U^vQ.n T90M f\ddr<-ss) il^\jilJU^.(DJ<in
EC^AL Information only ' " ^ ^
Special information only tor Hospitals, institutions, TransienJ^
or Recent Residents, and persons dying dWdv from home.
31 )>„•;.
1 /.-»'///.
Former or
Isudl Residence
Wljfn wa« disease contracted,
If not at place of deatli ?
fioM long at
Place of DeatI) ?
Days
rin. \Ho\j-: nt \ n- i. i-kksoxai. i-ak ncci. \ks \ki: thd- t. . thj.-
IJhSI Ol- MV KX0WIJ:I>C.K AM) UICI.IICK
J'l^CJC OI; lU KI^I, OR RKMOV.M,
rNi)i:RTAKKK \.\j.\J \J^i-^\\yY\j^^ 'H K,
HATJ;;^.,! ]U uwi. or ki:m()\-ai,
l^ I90H
{â–
N. B.-
Ttrt^c'rir^rUf nTri-'r**'"."''' "' carefully supplied. AGE nhoulcl be statc.l RXACTLY. PHYSICIANS «houId
VI A '\* «» Dr:ATH m plain tcrmn, that it may he properly classh'ktl. The ♦'Special Infformntion" for dt-
sons dyint away from home Hhould be <ilven in every instance.
m
\
t]
-if)
■»i
«!
i.,'
*
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
H.):ii.l nf HiMlth l-'No. 1^ 1*^^^^n&PCo
RCFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
'; »
b
I)(f/r Fi/cf/,
L^
1.1
100 H
Registered ^''o. ^ Q40
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( "CI. S. StanDarC> )
PLACE OF DEATH: — County ofO/<X/>\. 0;vcxa^.^^l^cc City of ^"^'^CUV^ 0 /vxXoa^v.,Aye c
Wo.\
i.
}JL
>\sK<xXj K.^^\\.^\.al: St.;
Dist.; bet.
and
(ir OCATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
J\XX.^r\)
si:\
DATK OI- lUKTU
PERSONAL AND STATISTICAL PARTICULARS
C<)I.()R \
ll'>Ajk/
M..iilh)
ACK
bS
Yrai
<I)ay)
^/>»lf/l^
(Year)
Pii ys
MEDICAL CERTIFICATE OF DEATH
DATE OF ni
UwAA/
(Month)
r
•I t
II â– â–
SINC.l.K. MAKKIKI).
WIDOWKI) OK DIVoKi'HI)
(Write ill sfK'inI (K'sij^iiatimi )
BIRTH IM.AOK
(St.'itc or Couiitrv)
NAM1-: <)|-
FATllKR
HIKTHI'I.ACK
OFV^ATHHR
• State or Ci)uiitry)
MAIDKN NAMH
Ol MOTIIKR
IUkTni'l,At'K
OI MOTIIKR
(State or Country)
(Day)
(Year)
KRI'HV CI{RT1FY, That I attended deceased from
Qv\d I90H to LAa-a^. I.hl i^S,
that I last saw h •.*.-< i^ alive on LMwA^Q 1 H T90';
and that death occurred, on the date stated above, at 105
.0 M. The CAISH OF DIvATH was as follows:
..<X
^^
M
â–ºCCI'I'ATIOX fd . ~? 0
DURATION ' }'ea/'s ' MoNi/is" Days Hours
coNTRimrroRY >J!ir^J^.Ar)nJ>.^..0>.c:^
DURATION ^ Years Months Days
( SIGNED )"^,.^J/OAJkJl^i cDjJuUttxj
LLc^O, IH iQO*\ (Address) U', 8. Lv.vJjl/vJL W.CH^^
Hours
M.D.
.^ IH iQo*
ecPaTTnr
Rf^idfd in S\in /'i iin, i^rn
) 1 III
M.uifhy
Ihn:
THl", AHOVK STA'n:i) PHRSONAI, I'A KTICn.ARS ARK TRl'K TO THK
HKST OI- MY KNOWI.KDCK AM) IIKIJ1:F
informant \K^ (j . LL- Vj
Ji/^r>JU^^.<^.
Jc OK) {y<4^vt txt
(A.l.lress
Special information only for Hospitals, institutions, Transients,
or Recent Residents, and persons dying away from liome.
Former or -V ^ P f How long at
Usual ResidenceO Oyyu JAxx^vuCA-^Co uxq»iafe of Oeatli? CLC Days
When was disease contracted,
If not at place of deatli ?
PI.ACE OF BIRIAI, OR RKMOVAI. I DATK of BlKlAI, or REMOVAI.
r.NDKRTAKKR Hk . \J T V - oLJ J^^txt
' U. i CL
(Address
^' B* F.very Item o? infformation shoulil be CHPe?ully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special Information** for psr-
sons dyinft away from home should be ^iven in every instance.
m
I
•'i
("â– ^ulJ^
r
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Jloai'l of llr.-ilth I" No. i^
n& I' Co
RCFER TO BACK OF CERTIFICATt FOR INSTRUCTIONS
iXtfe Filcil, (jLa^^va^ la I'^O 4
"^ ' '^ - Deputy Health Officer
Ee^lsteved J\^o,
1041
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtiftcate of 2)eatb
( la. S. StanDarO )
% J t % ^
itv of £J v) CPv\XKAaJ(.xv
(No.
PLACE OF DEATH: — County of
(IF DEATH OCCURS AWAY FROM USUAL
IF DEATH OCCURRED IN A HOSPITAL
City
St
*
♦t
"Dist*; bet/
"and
RESIDENCE GIVE FAC
OR INSTITUTION GIV
FULL NAME
'ACTS CALLED FOR UNDER "SPECIAL INFORMATION" "N
E ITS NAME INSTEAD OF STREET AND NUMBER. J
^\.^' O
PERSONAL AND STATISTICAL PARTICULARS
^KX A _ : I COI.OR N A
^maJ.
kx
DATK ol- IIIKIH
.\<.H
0\.
MEDICAL CERTIFICATE OF DEATH
DATE <>1 i)i:atii
(Day) (Year)
OiLith)
L
• Month)
3 rllS...
(Day) (Year)
J^t^ Yra,s h
Months
Dii r.v
SINC.I.K, MARklKD
\VI1)«)\VHI) OK DIVOKiKD
(Write in scxMal <l<si>.'natinn)
KIKTHPI.AOK
(Statr or Countrv)
VAMK ()|-
fatmi;r
HIRTHIM.ACK
Ol" FAPIIKK
(Statf or Cojintrv)
MAIDKN NAMK,
or MOTHKK
HIRTIIPLACK
Ol- MOTHKK
(State or Conntrv)
XA'AJrU>
VCr^U->v
, ) V.
d
(^"y^M-U-^-v
I HHKl<:nV CI'IRTIFV, That I attetidcd deceased from
— to
190 to 190
til at I last saw h alive on 190
and that death occurred, on the date stated above, at '
M. The CAUSE OK DIvATII was as follows
.'^.«<L/*w/-vv^ft<.:'V^^ L\J. .^tA-a^-w^cL,
DURATION Years
CONTRIIU'TORY
Months
Days
Hours
\y
•«
i9|^cxv iL- i. a
OOCrPATION
Rrsiitfd ill S(jv f'l ant isro
cars
Mouths
Days
DURATION ^
(SJGNED) UtlOl-^ A.U^XxJkAA.
I iqoM (Address) (ibcr->M)XA^J[^ ^.A..
Hours
M.D.
SPECIAL INFORMATION only for Hospitals, Institutions. Transients,
or Recent Residents, and persons dying away from home.
Yrai
M.niHn
Da 1 .
TMK AHOVK STATi:i) PKRSONAI. I'ARTICrKARS AKK TRIK TO THH
IIKST OK MV KNOWI.KDC.K AND BKMKK
(I
nfonnant \l /UCXa^C^ V' • IA • oUjLA.rtr\.'
(Acldrcss X>-U \A.- C^^ dU
XX/\hv^
Former or
Usual Residence
When was disease contracted.
If not at place of death ?
How long at
Place of Death?
Days
PI,ACE OK RlRIAr. OR KKMOVAI, I DA'i;K of Bi RiAi, or REMOVAI,
iL. -^ a'
UNDERTAKER
(Address
^' **• Every item o? information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information** f©p per-
sons dyin£ away from home nhould be ^iven in every instance.
S\
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I
lU.anl of Wealth K No. in
H& P Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Duto AV/^v/,XL^^ 1.1 IDO'A
0 oLx/v-u Dep'^jty Health Officer
Registered J^o.
104
o
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of ®eatb
( "a. S. StanOarO )
%
PLACE OF DEATH: — County ofOcL^^ 0.>vOLVLCc0.cc^^City of ^€U>X/ 0.\xx^^i:iA><i.
cc
^No. 3 b Cn^vUrixxCLi VI. <: CJxX/vuxLr VcStv; ^ -^ v Dist.: bet.
and
r \r Di*TH OCCURS *W*V FROM USUAL R E S I DE NCE C I VC facts called for under -special INFORMATION" \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER )
FULL NAME
SK.\
DATK «)|- lUKTM
PERSONAL AND STATISTICAL PARTICULARS
I COI.OK
u-
a^Mr>v
VC
±JL
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH
a(;k
iM(iiUh) K
\^
Vrun
%
lb
(I)av)
Mont//.'
(Vt-ar)
(Month)
1
(Day)
(Year)
An.v
SINC. I.K. MAKUIi;i)
\VII)»»\VKI) <»K DIVORCKI) ^
• Wiitt ill ><(H-ial (li'si^natioti)
HIK TflPKAOK
(Slatf or C'otintrv)
NAMK or
fathi;r
RIKTm'I.ACE
^)r- l-ATHKR
(Statf or Coutitrv)
MAIDKN NAMK
OF MOTHKK
rtrthplacf:
of mothkr
(Slate or Countrv^
^I HRRERV CI{RTIFV, That I attended (leceased from
^^ 190 "i to .LUaa- .1.1 190 H
that I last saw h A. S. alive on
^<\- \^- 190H
and that death occurred, on the tlate stated above at ^ 3) C
A M. The CAUSfv OF DHATII was as follows:
^ "^ - • -- V/CXA^<lA./-VX^cr^v\.rCU
f\AJL
^^y\J
Kd
'CC^JL'<ry\j
DrRATION 1 Vearp^ AfonU^s ^ay/ Ho,
CONTRIBUTORY L<X^^..dLA./lX^ i /a..vlA,Ajrv^.
Davs
Hon
")
c^-v
cLo,
M
OCCIFATION O
Rfsidrd ill ."^u f'lan.isrit
T^
) V-,,-
1A. ,////,
DURATION ^»^A^ ^Mouths
(SIGNED) y. bU. Vjtfti^ M.D
^^ rqoH (Address) (9 Ob OAvtU^U 3l
« ^^^ D uK "^f^^'^'^T'ON »"'y 'or Hospitals, Institutions. Transients
or Recent Residents, and persons dying away from home. 'ransients.
/)(/1,v
J
HKSTOF Mv knowi.fdc.f: AM) iu:i.n:F *'
(Infunnam \. & Am^OLA.v(6-C C, K
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How long at .
Place of Death? I Oays
.'I, ACE OF niRIAI, OR RKM
e
I)ATF:of HcRiAL or REMOVAI,
^'^ T90I
li
t
i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
'f
2?V:.
, •
Honnl of llialth- I- No, !«; ■5*er':St'3ri5 ){& I' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I ,
l)nh> /vV^^r/, UwA^^^-O^^^ 11
WO'K
dv^r^-^'-'^-o
Registered JsCo,
043
Dep jvV Heafth ?
â– j.
DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco
Certificate of ©eatb
( 11. S. StauDarD )
PLACE OF DEATH: — County of vJ CTWXrry^wOu City of VJ Crvy^^CTYlOyOu
No.
St.;
Dist,; bet.
â– and
f IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION • \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
-:n (^
0X/»\X5j(jL
COI.dR
rVAAX
I>AIK OJ- lilKTU
Ai.l-:
HS
)V:,V
1
H
(Day)
1A';////>
fVear)
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATH
(Day)
sA^<-^WQ
(Year)
10
A/r.
sr\C. I.K MAKKIHD.
WIDOWIID OK DIV( »K» Hr)
tWritrin social (Itsij.'iiatioii)
OJXXXX/CL
J«'l
i
lukruri, \ok
'Slate or I ■' Hint !■^•
NAM1-, ol
I'A'IIU'.K
IUK'n(l'I,A<K
0|- lATHl'.U
'State or Cimiitrv*
m\ii)i;n NAMi-;
•)I MOTMKK
UTKrifl'LACK
Ol- MOTHHK
(State or Country)
occri'ATioN Qy
(Month) ^
I HI<:RI<:HV C1:rTIFV, That r attcMia^rck'ccase<rfroni
■190 to •
that T last saw h
alive oil
190
190
an.l that death occurred, 011 the date stated above, at
M. The CAUSK OF DI-ATH was as follows
vJ -^-A^\JL<r>AAiA^
CL/>X' vj 7VXXy^ry^x:.o^a o
1 f
1)1' RAT ION Years
CONTRIIUTTORV
Mouths
^ays Hours
M
or RATIO X
ll
Years ^ Mouths Days Hours
(SIGNED )..\]/OL/cL O. "QLjvXXOL^*^
i^ 190 H (Address) O CTv-uirvv^^^ Cal;
M.D.
?^^9*ftK "^f^"'^'^"'''ON only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
'•i'.fd i,> S.I)/ /■'} ,ni, i-rn -^ )',-,i;<
M.,„lh^
n,n
hi: MIOVI-. STAIJ-.I) I'KKSONAI, I'A KTUf I,A KS A K I' TKD- T« » Till-
m.sT OJ- Mv KN«»\vi,i:i)c,H AM) hi;mi:f
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How long at
Place of Death ?
Days
(Info: jn
I
( X.l.lrrks
T90H
'^- R' fivery Item of iii?ormHtion should bt
^Ji'^*^^' <>»^A^KIAT, OK KHMOVAI. DATK ,,f HnuAi. o, KKMOVAI,
r.NDl'iKTAKHK
(Ad(htss
^4
state C\IISF or nr ATM ! . . '"^ '="''«f""y f"PP'"=^«- AGF. should be stnted hXACTLY. PHYSICIANS should
««n. 1 -1 c T" '" **'"'" **^'''"'' *''«* " '""^ •'^ properly classified. The 'Special Information" for psr-
«on« dymft away from home should be liiven In every instance.
t
i'
';..â–
I f
'if'-'
r
i\
.Ji
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
n. tnlnf n.tith- h No iii^^^H&J'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dff/r FiJrd,
^ OsJi/\)^^
...1.1
lOO'i
Registered J^o,
1044
DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco
Certificate of H)eatb
( "Q. S. StanDarO )
(^
PLACE OF DEATH: — County ol'^OJW) J .>\^Cl/>\/xa«(. City ofOcVrvj dAXX/>vC-A-^<:u;
'No.
:i.:
.c^t^jcL..^ <]\: cr<i.^
^|vX<xl
St
Dist«; bet«- and
-v.n_. I ^^.j J ^_ u >a^' v^^^^v^.^. :>t4 .JJist*; ben- and -
/ ir DC»TH OCCURS *W*vl FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SRECIAL INFORMATION" \
V. IF OtATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
SJO
Xi
DA'll-: «)l- lUKTII
PERSONAL AND STATISTICAL PARTICULARS
I COI.OR
N
K^-
ijL
^
<XKj
I Month)
AC !•:
So V,a,s ^
n
(I)av)
M.tHtfiS
r 'I H L .
(Vcar)
MEDICAL CERTIFICATE OF DEATH
DATE OF DEATH
l.L,
(Day)
(Month)
A? ij
"^1N<.I,1-: MAKKIKD,
UIDOWKD OR DIVDKrKI)
'Writiiii siK-ial <l«.-»;i>^n:ai<)n)
niKTMlM.Al'K
(State or Country)
NAM!-: <)|-
FATHI-.R
lUKTHIM.AcK
ni lAIHKR
'Statf or roiintrv I
MAIDKN NAMF
<)| MOTMKR
i9o\
(Year)
I HKRHHV CivRTIFV, That I attciKkMl <leccased from
^Jp^M 3^^ I90H to .LU,A^...l..(c itp^
1 111
that I la.st saw h ^.vS' alive on LCvs-<V ' 16' IQO '1
and that death occurred, on the date stated above, at 3- XC
U-M The CAISIC OF Dlv.ATH was as follows:
\>J<\:^\^^rY\.^S<:L .vrXxkJvx^utXo
niKTiII'LACK
()!• MOTHFK
(State or Countrv
oocrr'ATioN
Years Months
Days
v/VU^L/Lciyi^^ 6~
I)l'R.\TION
CONTRIHUTORY
DURATION Years Mouths Days
( Signed ) Uj.- \j CvvJL^i^-'trvv
U. 190'! (Address) at.
Hours
M.D.
ly^^i:.
Rfsidnl in San Fiaiiii.^ro W )'iuii s
U>>i/f//s
n,i 1 .>
'"" ».^"^^^'^^ STATKD I'KRSONAI. I'ARTICr I.ARS ARK TRFK To TUF
llhsr Ol- MV KNO\\Ma)C.K AND HICIJKF
(Informant xL . o(d JOojJL
SPECIAL INFORMATION only for Hospitals, Institutions. Transients
or Recent Residents, and persons dying away from home. '
Former or
Usual Residence
When was disease contracted, ICl 4-
If not at place of death? \J..^ ^3j>.^
Days
\<1(lrfss ^l^
ii
PLACE OF BFRI.M, OR KHMOVAI,
INDERTAKER db /oJuLtX-'dL ^ Cc
(Address .C\Wq >ftVA^^x<L^.,:(r>A...B^^
'^^''"'<<>f HiRiAi. or REMOVAI,
190H
N. B.
rtflVe^^C^ir^F^Ap nTri-M".***?'.** ^" carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
!«- % r^ OF DEATH In plain term., that it may be properly classified. The "Special Information" for per-
«on« dyinft away from home should be ftlven In every instance.
^
f
J
1
t .
''
} A
m
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
â– (
â– <
i:
If H'
1^ H
I .
M »
m
If. . ,11.1 ..r llraltli- !•• Vo. K f'-^-a^^'. H& I* C
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/)(f/(' Filed ,
^y\J<^\A
11
lOO'A
Registei-ed J^''o.
Deputy Health omcer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of E)eatb
( XX. 5. Stan^ar^ )
No.
PLACE OF
DEATH: — County ofO/Cb^ru J AXX/>vC>c<l/CcCity ofC)<X/>^ J -^XX/vvytM^^i/c^o
0 VA.KX v<:^^
(
SU ^ Dist.;bct. b
\'
and
1
I F
ATM OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL I N FO R M ATI O N '• \
DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME
.CL;V-V<L iJVl'AA.4^'
^(m„)
Ni.\
1).\!"1" < >l lilKllI
PERSONAL AND STATISTICAL PARTICULARS
t'ol.oK
M..nt!i)
A (■.!•;
(dO
)â– .,//
(Dav
lA <////.
< » far)
/)<M,
MEDICAL CERTIFICATE OF DEATH
I).\TK <n- DIvATlI
15-
190 H
(M<Mith) /T (Day) (Year)
I ni<:RI<;HV CI-RTII-V, TIimI I attende.l (Icccased from
\M^
\*p
tu
S!N<,I,K, M.AKkll'l
\\ ri)n\\i-:i) OK i)!\'( >Ki i:i)
Write ill vooial lit-iviiatiDii) |
iiiK rniM. \ri-:
state or (.'1 mnti \
NAMI': 01
!• A THICK
P.IKIII I'l. Ml-:
•»!■lATHl^K
< State or Coiniti \*
A^VXLaLvXXj
^v.
liat I last saw h rV^^^ alive on yVA./%
â– vJL iC
IC)0 -
I90M
and that <katli occurred, on the date stated aluive, at 0
^ M. The CATSlv OI- DIvATlI was as follows:
• "^ ri'A'i'ioN
Rr.iifri! lit Sr.t' /'niu.i-.-n J^O )'rii i • - M,.):tJn
MAID); N NAM1-.
or Mo'IMIi: K
IMK I*HlM,Al"l-:
ol- M()Tni-:K
(Stale or I'oiintrv)
DIR.VTION )'rars
CONTRIHUTORY
M<nit/lS
Days
Hours
Cj AA^cL/cL.«>^vAj
I )!' RATION
(SIG
)'rars
jV>);////s
NED )\1 itojvt^^v ^XlLqX-vwLo
/)(7 rs
Hours
v<|x>v ^ M.D.
i^ iQoH (Address) "feO^ <0 J^ttiK. Q^t
Special Information only for Hospitdls, institutions, Transients
or Recent Residents, and persons dying away fron fiome.
Former or
Usual Residence 10
ihi
Hil)&w<iva.ib!!,r:;vi,h;
Wfien was disease contracted,
If not at place of deatfi ?
Days
fi
iin: AH(>vi>: sia ri:i) i-kkson \i, I'AKTicn.AKs aki- tkik to thf
iiHsT oi- \\\ kno\\t,i;i)<;h and hi:mi:k
f \-Mress
^ SH
!N. B. H
ri,.VCK OF RfRIAI^ OK KKMoVAI,
I)\rHo! Hi KiAl. 01 Kl-:.MO\-Ai^
n
ni>i;ktaki:k Jo OJLciXc<JL ^^ Co
T90 V
Ad.hess ^Hb VjrtvA,/^^
s^-w, ^±.
Hvery item of information shoulil be cnrefully Bupplied. AGB Hhould he stotecl EXACTLY. PHYSICIANS should
state CAUSL OF DEATH in plain terms, thnt it may be properly classified. The "Special Information" for o.r-
«ons dyini away from home should he Jiiven in every instance.
* I
I
p
1' I
r
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
H.unlof HcMlth- KNo .s*^^H&i'Co RCFCR TO BACK OF CCRTiriCATE FOR INSTRUCTIONS
Deputy Health Officer
Registered J\^o,
DEPARTMENT OFPUBLIC HEALTfl-City and County of San Francisco
PLACE OF DEATH
'No.
Certificate of 2)eath
( Ta. S. StanOarO )
: — County ofO;CL/T^ OAXWuCAA^ City of C)OL/ru JAxX/vv<i.c><ML<)t
5 ?) C) cL<JLh6\Xi.j St.; I 0 Dist.; bet. WLLA^Uvo and '^1 L.{SX
f \r OE*TH OCCURS AwAV rROM USUAL RESIDENCE GIVE facts called for under "special INrORMATION- \
V IF DEATH OCCURI^ED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
si-:.x Qo^ jj I coi.ou^
DATK Ol- lUKTU
)M^OJl
iMotith)
(Dav)
(Year)
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH
,15,
(Day)
nAa.^,1
(Year)
A(.K
V \ VliD > c^
Months
0 ^'
Da 1 :
SINC.I.K. MAKK IKD
UII)n\VKI> (»K I)1\'MK( HI)
iWritf ill MK-i:!l (hsiiMiatioii)
MIKTHPI.AOK .
(Statf or Comiti v'
\Xax^v.o-^cL
(Month) C\
l^HKRHHV CICRTIFV, Tliat I attended deceased from
190 o to
that I last saw h -V-^J alive on
GU.^
190 H
^ 1 190 'i
and that death occurred, on the date stated above, at 3.3) 0
Uk. \l. The CAl'SK OF DKATil was as follows:
VAAje,
^VVU
NAMK OI
FATHER
MIKTI!I'I<A(F:
OI- l-ATHKK
istatf f>r Country)
MAIDHN NAMK
OI- MOTHKK
lUKTH PLACE
<)1- MOTHER
(State or Countrv)
(^
^ Jb'y^M^^^YWX/W)
O/cJlsi^j
DURATION I ^ea,r^ i^^^wXT^^^
CONTRIIU'TORV
oys Hours
i^jiXXjs
MfloAxXr Lcrvl
x^yy\)
ty^
DURATION }^ars Mnnths Days Hours
(SIGNED) MfWuuL ^aj3un\s M.D.
n TQO H (Address) 111 "^X^t^A^ Bjt
OCCUPATION
^^^^^y}^^OnfAIKT\OU only for Hospitals, InstituUons, Transients,
or Recent Residents, and persons dying away fro.u home.
M,„ilh< " Dn\
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
Now lonq at
Place of Death? Days
'''"V:;^"i.^^'*'' STATED I'KRSONAI. PARTICn.AKS ARE TRIE To THE
IJhsroF MY KXOWI,EI)C.E AM) BELIEF
(Informant yCUWvJL/) LULvl/vO
PI^CE OE niRIAL ()R REMOVAL I l)ATl< of IJtKiAi. or REMOVAL
rXDERTAKER 0&V<AJL/TV U /CXAX
I90H
jAiMress XH-S. '^ .,.\fi\«A.XLAA.<r:YV. ^..^t^^
^' "*~rt«V/cl'im2*A"JnTri?M" •*'7'.** ''*' carefully supplied. AGE •hould be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH m plain term., that it may be properly classified. The "Special Information" fsr i»er.
«on« dylnft away from home should be given in every instance.
r
â– 1
w, f '
"A
\^
I!
m-
V.
i
'^'
' 1
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Ho;inl of Health- FN
o. i^
H&l^Co
REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
Drffe Filed,
11 190 "{
Deputy Hf^afth Offioer
Registered J^o,
1047
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of Beatb
( "Cl. S. Stan&arO )
J? (5} . \ ^
PLACE OF DEATH: — County ofCj/CU>v J/uX/TtCiAOCity of Cj/O^^nj J J\yO<jy\S:AJ^<U.
''0
^No.
D^!-^
oAXxxiCi
St
Dist; bet. and
/ IF DEATH OCCURS AWAY fROM USUAL R E S I D E NC E Cr V t FACTS CALLCD FOR UNDER "SPECIAL INFORMATION" V
V IF DEATH OCCURRCO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER J
^P J? -^
)
FULL NAME
\^\JLu
PERSONAL AND STATISTICAL PARTICULARS
U^la
DATI-; <)I- lUKTlI
Ar.K
tMotitli)
In I
(|)MV)
M.'ulh^
fYcar)
Ji
MEDICAL CERTIFICATE OF DEATH
DATK OF I)F:ATH
' ' I.b,^
(Day)
(Year)
A; I '.«
SIN(.KK. MARKIKl).
WIDoWFD OK nn'oKCFD
(Writiiij •^(K-iHi (lcsij.^niitii>iil
K^Ji-.
,a.
mKTMPUACK
(Stiite or Coimtry^
NAM)-: or
FATUFR
HIRTMI'I.AC K
OJ- lArUKK
'State or Country'
maii>i;n namf
«>l" MOTHHK
niRTjrpr,ArK
OF MOTMHR
(Statf or Couiitrv)
I HKRKBY CKRTIFV, That I attended deceased from
^ 190'"^ to ....UwA,.MX.....l.!b. 190 H
that I last saw h-^vn alive on VAa.aX3l \ b igo H
and that death occurred, on the «late stated above, at
^ M. The CAUSK OF ])1':ATH was as follows:
^^-^^^:-Aw\AX ^ ^JCOwt/od^^t^-v. fe..re.-OLAJL
U<Lf<:L.^ir^r^,jA,^.ry^
DIRATION
Years - Months ^ Days X Hours
CONTR IIU'TOR Y '-i-^i/^^X/V^A^Jl<^^
DURATION Years Mouths
OV
P
occupation ^ . () A
(Signed)
k)., ^i. CJ I
n 190 4 (Address
f\f>idfd ill Sim li ii III isiit
) til I
.lA»;////.v
/hi
^^^,<i^^,^,^^^ORM/KT\OP* only for Hospitals, Institutions, Translfnts.
or Recent Residents, and persons dying away from home.
Former or M |
Usual Residence dJxx/vUi/YyxUA^xj w>^x ^^ff or ueatli7 U Days
Wfien was disease contracted,
If not at place of deatfi?
u
How long at o
Place of Death? h
THF. AIU)VKSTATi:i) I'KRSONAl. I'ARTICF I,A RS A K I". TRIF To TIIF
IHvSl OF MY KNO\\l.i;i)<-,K WD Mi:!.!!:!.-
:}%
o
^'^'tf\5 '^'V^'^Io'' ''^ '<»^'^"»^-^I' I IMTFof HiR.Ai. or KEMOVAI,
INDKRTAKKR LvWAjtt^i^
(Address 0..(a lo. M'\A-/<5^'<L'U<rVx ,3:^.
N. B.-
-Bvcry Item of information should be CRr«fully supplied. AGE slioiild be stated EXACTLY. PHYSICIANS should
state CAUSE OP DEATH in plain terms, that it may be properly classified. The "Special Information" for Dsr.
Rons dyinft away from home should be t'ven in every instance.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Hoard of Health— I-' N'o. i^
H
1 I
M
fii 'I
fr^H&PCo
REFER TO BACK Oir CERTIPICATr rOR INATRUr.TIONA
!)((/(' Filed , LLooOL
Registered JSi^o,
1048
A.v^t va ioo\
M^ Deputy ' â– fth Om-cr
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Death
( "U. S. StanDarO )
PLACE OF DEATH: — County of OkX'^\; v) AXVYVCA^cxCity of O/Cuw 0 A/CWvc^.^^<.
(No. ^^t^r^L^w^xt^, 'db CH^KAial'. St.,
-^vvvYvv^t ^'^^>^i-"U^Ci.'... M.; — — Dist.; bet. r and — — â–
/ ir otATH occuRsUwAv moM USUAL RESIDENCE civc facts callcd ron under "special iNroRMATioN- \
V \r DEATH OCCUf^RtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
â– )
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
<X<X/sLA.;
^i;\
flwL
COI,(>R
DAI i: «>l I'.IKTM
A<.H
lUvvi
M..ii\)i)
(Day)
V
oU
U-far)
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH
^'\ 1V,„.
%
M.iulfis
at
Pa ) :
'^IN'.I.K. MARK IK I)
WIDOWKI) OK niVoKrKI)
•Write ill s<Kial •hsiti'nation)
niKTn»'i,ACK
'StMt«- or Coiiutrv^
NAMK Ol-
HIRTHPI.ACE/l I
OF FATMKR A
'State <,r Country) V ^
(^*""th) (J (Day) (Year)
I HICUl-HY ClvRTH'V, That I atteii.le.l .leceased from
. Ll^OAA^i IC 190*^
that I hist saw h
to >.. l.A^.Q,....l.L
o.- 1-^ 190 H
alive on V.AAA.CIL 1 V 190 -H
andthat death occurred, 011 the date stated above, at O. QLO
^^^ M . T h e C ACS \\ 6 V 1)1 < A T 1 1 was as f ol lows :
%Mr<lX^VOrcOj . O^ct VI )WtrC>Cu\ycL<^/C^
(d v3-v>A.lN^'du
S)
'1'
<XAA.
I) r RATION
CONTRIIU'TORY
Years Mopit/is Days
LiXc<m.£rVA
Hon PS
r.\.^a^.7vx.
MAIDKN XAMF
Ol' MOTHKK
hirthit.acf:
Ol- MOTMKR
(Statf or Couiitrv)
occri'ATiox (^ n
_ 0 XKrv^^ <Xyy^
A font lis
Days
V'.
Hours
M.D.
Rfsidfii in Sat) I'l a>\i iso '^\. Yrai^
yr,niiii^
n,t\.
'"'' HF^ST nr'^Tv'u-l!' !;»^K.^'>^"A'. I'ARTICFLARS ARl- TKIK To THK
iJF.sroi. M\ KNo\V1.1-;D('.f: AND IlKMFtF
{rnformam UJ />>\; . \H\ - Xo-^^^^Lt V
DIRATION Years
(SIGNED) LUm\;.m- axx.^v^L\;
'"^ 190H (Address) LuLXc Cq. fe CML^^;!-
When was dIsMSf contracted,
If not at place of death ?
Place of Death? 116 Days
i\iU
rc'ss
N. B.-
W^%L Co . iV) CHi.^vvt'OLi
190H
PLACH OF HIRIAI, OR RKMoVAI, DA'i;Kof H, k.al or RKMOVAI
JM, Qivv^ I (W...i t
INDKRTAKKR OX) â– O. M / C<X <VAXi/ L<;
(Address
•tate cIirSE OP nTrxH I . carefully •upplied. AGE should be stated EXACTLY. PHYSICIANS should
««nr,i : ^ DEATH In plain term., that It may be properly classified. The "Special Information" far Mr-
«on. dylnft away from home should be ftlven in svcry instance. 'ormation rar psr-
'11
< i
•J
'1:
'ii
,. i 1
1
jJII
{
J
1
\i
â– Bl
i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I!.,:Mfl ..f Hillltll -I-' No. U
-i^^^!^:
HJX:!' (V>
Dale Fileil ,
m
ifcrfcniw anv«r\ v»r v^cn I i p iv^A r R. r'Uli INSTRUCTIONS
11
lOO'i
Registered JVo.
1
Deputy Health Omcer
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Ccttificate of Death
( Ta. S. StanOarO )
Jj 07) . -^ ^
PLACE OF DEATH: — County of ^'<Xa-u -J-'UXAveA.AAU.City of Ooyru 0 AXVyvca^-O-CC;
'No
.l\%
.<X'
St.; Dist.; bet U OU>x<L(r»\ji.;
and
( *' ?J'V** <'4'="''* ***^ ^"O** USUAL RESIDENCE GIVE facts CALLED FOR UNDER "SPECIAL INFORMATION • N
V IF DEATHJOCCURRCD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER )
{TK
FULL NAME ^J.â– ^L/yx<iJUy^^a/:^
If!'
\
♦
1 '^..iv
SK\
PERSONAL AND STATISTICAL PARTICULARS
COl.OR \
I
UoJuL
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH
n.M 1-; n\ lUKIH
Af'.K
I Month) \
I
(Day)
M.oiths
(Year)
/hiy.
(Month)
(Day)
i9o\
(Year)
^IN'.I.K MAKKIi;i).
WIDnWKI) OK DIVomKI)
tUiitt ill s(Ki;il <ir«.i>.Miati()ii)
HIK rniM.ACK
'St;itf or Coimtry'i
NAMK Ol-
iatmi:r
niRTTIPl.AfH 1/
Ol- l-ATMHR
<Statt' or Country)
I
<X/vN-^jui.
.^-(X'Lo
.o^a
I irrvRHRV CHRTIFY, That I atteiide.l deceased from
190 "-rr-
190
that I last saw h
190 to
~ alive on ~~
and that death occurred, on the date stated above, at -
f /rhe CAl'SR OF Dl^^TH was as follows:
?wA..
Dr RATION Years
CONTRIBUTORY
Months
Days Hours
MAIDHN NAMK
0|- MOTHKK
HIRTHPt.ACK
OF MOTMHR
(Slate or Country)
J
DURATION ^>V.7;'5 ^ Months ^ Days Hours
(SIG
NED)..J..-iE..ljQ.ljLLx^.
LLa^S^Q Q TooM (Address) Lfr*UfVaA-^\!Jv
-all iQo'
iCIAL INFC
\i M.D.
^^^Jt^'^^^^^ORfAIKT\0^ only for Hospitals. Instituhons,
or Recent Residents, and persons dying away from home.
Transients,
OCCUPATION
^^•"'tM in Sdn J't^tuisro I S )>«?;.
Mnnt/ia
Par.
"ll
'^"HK^T y^^^lvV:/^;!* T'HK^^OXAI, I'ARTICn.ARS ARK TRIK TO THK
HKSrop MV KMOWJ^KDCK AND BKUKF
(Infonnant \J \y-^^UU^ M)XcX^<L/Cl^x>oJU^
Former or
Usual Residence
When was disease contracted.
If not at place of death ?
How long at
Place of Death? Days
(Add
ress
.oJLXju^ *3j:
PI.^CE OK lU-RIAI. OR RKMOVAI, | DATK of IUriai. or REMOVAI
IINDERTAKKR L oJlC/VnXx ^TK^XA^Ovvvj '^M.
i'O
(Address l.S.XH
m.
mm
""' "* .^t^/cll'sE'^OF dTItSI'^ *' '""•^"J'" f"'*'*""'*- ^"^^ •''""•^ **• •*-*'^ EXACTLY. PHYSICIANS .hould
«oni dyfn Aw«r from^ome ^i" M K •":.• "' '* """^ !*' '"•"''*''*^ classified. The "Special information- for p^r-
• • u^'inn away from hpme should be (ivcn in svspy instance.
u
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I.
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I! P
)â–
f
: 1
^ f
it i
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WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
M.iai'l.'t lltriMIi- I- No. n ^^OTJj^ »«: I' c'o
REFER TO BACK OP CERTiriCATE FOR INSTRUCTIONS
/>(//(' Filed ,
II
lOO'i
RegistereclJ^o. 1,050
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Death
( Ta. S. StanCarO )
PLACE OF DEATH: — County of ^ '<^^^' ^ Axxaaxxa^cc City of 0/Ol^W; 0 A^O.yTva<..<:L/C.c
1, % , .. fl
'No. 0 Jc Vvr^<X'>\; dbcKL'
^'\.JL<xX:'
St.
Dist.: bet.
and
( IF DtATH OCCURS AWAY FROM USUAL R E S I D E NC E CI VC FACTS CALLED FOR UNDER "SPECIAL INFORMATION \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
FULL NAME
Xa
V.<l/\^^A^O^'
SKX
DMK ul FUKTII
PERSONAL AND STATISTICAL PARTICULARS
COI,OR
'\jy\T
I Month)
XX /iHO
(Dav)
MEDICAL CERTIFICATE OF DEATH
DATE OF DHATH
AC.K
t)^ V.,n, \
.1 A -;////.<
ai
(Vear)
Da Ys
lb
(Day)
190 \
(Year)
SINC.I.K MAKWn:i).
wiixtuKi) OK i)iv()Rt'K[) n
Write in s<K-ial (ksijciiation) Jc
lUKTMPl.AOK
•Stjitf or Country)
NAMK or-
J ATIIHR
lURTMIM.ArK
Ol- FATMHR
• State or Country)
MAIDKN NAMK
<>»•■MOTHHR
HIRTHPLACK
Ol" MOTHKR
'State or Countrv)
I IIRRKBY CKRTIFY, That I attended deceased from
LL^a a 190H to LL-^....l(o 190..H
that I last saw h'<^v-rx alive on LLv-a_^ lb. igo H
and, that death occurred, on the date stated above, at 9
^M. The CAUSK OF DIvATH was as follows:
vVx^^rv-v^ \
OO'u.v^v^vH., Q.
.^.
o-v<i,,<rvu^.<<%:
^.
-t.
DURATION Years ^\ Months \'\ Days Hours
CONTRIBUTORY
nccri'ATiox
fir.^ided in Sav l'tatiii<fo 10 Vfata
DURATION
)V|^rj
Months
( SIGNED ) ...UJ. , 0 (h C^4Jk.^./v>^
n -^
^>^^^^q 1^ IQOM (Address) V)
SPEdlAL INF<
Davs
Hours
M.D.
) "^-^^-Vyyvo/^x/. ..m
^fnllt/l.y
Dn \s
'^" nvJ-r^y.?.';!;^''^^''' •'HK^'^NAU PAKTICII.ARS ARK TRIK TO THK
Ilhsroi. M\ KNOWl.KDC.K AND KKMKF
(Infonnant J^CV/V^XOw^W
D . D .^ . IfORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from liome.
Former or ay "1 1 How lono at
Usual Residence ^ UU^vvi^^LU (Jl piare of Death? 10 Days
irv^ryv
When was disease contracted.
If not at place of death ?
(Add
res.s
PLACE OF BURIAI. OK RKMOVAI, DATKof Hir.al or REMOVAI
.__tob_ mlZ^ I ulCx a
UNDERTAKER
(Address
YDL/^rrU^a Ik)
190
N. B.
rt«Ve*'crim^*n"Jnrfiu^**'7',*' **' carefully supplied. AGE .hould b« .tated EXACTLY. PHYSICIANS .hould
!! % . ^ DEATH In plain term., that It may be properly classified. The "Special Information'* fer u.r.
«on« dyin4 away from home should be given in •x^ry instance.
i' ',1
1,
V
\ w
t
'if
\
41
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
lln:(i.l..| llcilfh— I" No. 1 1; TP^jH«R^3 Hffc P Co
Â¥
n
I
I
I •
i'%
( f
t I
(!
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I)(ff(' FiJeil,
n wo'i
Registered J^o,
CA^
DerJ-^^^y '-J-^n'-*- Offlicer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( TO. S. Stan&atO )
%
PLACE OF DEATH: — County ofO/CLoo; 0 AxxavCc<lc<- City of OxXAV J Vou>vCA.<iXU
No.
IH
'.^\.v<:>
St.; I Dist.; bctX
and
r ir Dt*TM OCCURS *W*V FROM USUAL R E S I D E N C E C. V t facts CALLtO FOR UNOCR 'SPCClJl I N FO R M ATIO N • A
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREEtIJiND NUMBER. )
u (â–
FULL NAME
J..X;:>x^^ca\.j
UAJ
SKX
PERSONAL AND STATISTICAL PARTICULARS
COI.OR
1
yr
.<Xjl
I>\T1-: oi lUKTII
A OH
'Month) i]
11
(Day)
/iO.M
(Year)
Da ) .V
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATII
LAaa^
(Month)
1
l.k,,
(Day)
i9o\
(Year)
SINC.j.K, MARKIi:i),
WIDnUKI) OK DIVOKiKI)
'Uiitr ill sorifil «Usijf nation)
HIR rniM.AOK
(Stiitc or Country »
NAMK OI
I AT Mi: R
MIRTH PI.ACK
OI' I ATHKR
(State or Country
x^
I IIHRKRY CivRTIFV, That I attended deceased from
-^-^^^^^-^ l^ 190H to LUa^ Lb 190.H
that I last saw h'<^-.v^ alive on LLca^^X , 1 lu igo S
and that death occurred, on the date stated above, at \X, I 'o
A; M. The CAUSrC OF DKATH was as follows:
•■'^jAJL>v;. S....o^-wiu>.AAAiZXa
fVVv<y-QL'
MAIDKN NAMK HCS
OI" MoTHKR '()l)
Dr RAT ION Years
CONTRIIU'TORY
Months
Days
Hours
DURATION Years
a. a
Months
Pays
inRrm'i,A(M-:
'M- MOTHKR
(stall- i,r Country)
CCCiAAJ
Hours
I (SIGNED) LI. 6J-^ A.AA,^Ov^^ M.D.
^<^ n 190 H (.Ad(lross) '^^'^ yiWv-^
1
a.
?^^?'ft'-J'^f°'"^'^"'"'ON only for Hospitals, Institutions, Transients^
or Recent Residents, and persons dying away from home. '
i^lAL INFORI
v^fca^l.L\^4'.
'HCri'ATlOX
. ^'^'''f^'f "I S<i„ / ,,in, i.u'it - }V,ns - yf.uitfis "^ /hns
' " nrJ'r^r7.'^-^J,V'''-'> l*»':«^ONA I. I'AKTICf I.AR S A R K TRCK TO TIIH
Hhsroi. MN kno\vm;i)(,k AM) Hi;iji;i-
(I'.fonnMnt O . \l l\e W^^Oth^
(Address l^i \cyJtwo at
Former or
Usual Residence
When was disease contracted.
If not at place of death?
How long at
Place of Death? pays
fi OH BURIAI, OR RKMOVAT. D.VlH of ntK.AT. or RKMOVAI,
olu Gut^<l^. I vL-v^ \'l igoS
r XDK R TA K K R U <xXx/^<XX \^^Ux^.A/YVV "< Lq
(Ad.lirss IS'^H C) ^tv^L>|^^jt«ry:\^.....dl
"' "* rt7t7cMr8F*OP n7rTH",*''7V' **' carefully supplied. AGB •hould be .tated EXACTLY. PHYSICIANS .hould
^nnl H 1 / e T ^'"'" '"'""' **""' '' """^ '^'^ properly classified. The "Special Information" for Jr-
«on« dylnft away from home Hhoiild be Itiven in mvory instance. "^
^â– (:l
'iJi;
'1
* .'I
I â–
ti
' 't
1,
1 .li
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
l; ,1-.'. ..f flea 1th -J" No >«. t-^^^^HS:!' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Didc /vV^v/, LIa^w<u^^^ II
100\
.>&-VC>CCi
Registered J\^o,
105-2
DP"^'-/*"*' '.'->-> I* ». r-. rrr
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of ©catb
( Vi. S. StanC>ar^ )
PLACE OF DEATH: — County of LlLa>-> v<.d.<x City of
M3X>JkjLLvi Let I
No.
St.
Dist.; bet.
and
/ ir DtATM OCCURS AWAY mOM USUAL RESIDENCE GIVE FACTS called for UNDER "special INFORMATION
V IF DEATH OCCURRID IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STRrrT AMn Miitiar.
FULL NAME
IK
SK\
PERSONAL AND STATISTICAL PARTICULARS
I
)
â– )
^
mc^L
I'M K »>| ItlKlH
AC.K
J
1
KC\^<.
MEDICAL CERTIFICATE OF DEATH
'^VXcLO
.t.
Month*
is ......
(Day)
i Mo„!hs
^f
V
(Year)
DiJ 1 .V
DATE OK DHATH
1.
(Month) 1
11
(Day)
(Year)
"-INt.I.K MAKKIKI).
w n>o\yKi) «>k n;\»»Rt"Hi)
N\ riff ill <(KiaI iU«.ij»n:itiiiii)
HIk rilPI.^t'K
St;ttt <ir Cmmti \
K<L<y\x>^\)
i^
I ni^KHnV ClvRTIFY, That I atteiulea (lecoasoa from
~ to
T90 —
that I last saw h ^alivc on
^90
190
ami that doath oconrrctl, 011 the ilato stated above, at •
M. The CAJLI^SK C)l< Dl-ATII was as follows:
\AMl-: n|-
I-ATHKR
lUKTMI'I.ACK
oi" I-^IMKK
'Stale .,r lNmntTv>
MAII)1:n NAM!"
<»I MOT! IKK
lUKTMI'LACK
<M" MoTHKK
'Statr or C«)uiitrv)
DVW,
\.A^>
DIRATION Years
CONTRIIU'TORV
Mouths
Days
Hour.
>vcrv<vrv\.
DURATION
Ytiir
Mouths
/hivs
ii
0_^.<x.yc>v\
*»
(Signed) ♦ 0, J.ix\.vo.. ..
Ua\0. tl Too't (A.Mress) \DxV.VU.Uci La..».
f fours
M.D.
%
Special Information only for Hospitals
or Recent Residents, and persons dying away from home.
i, Institirtlons
fCrsiifnf in San /'rain isrn
)'rnt s
y^niifliS
Du r>
"",;,:^"r*^'^'' ^'''^'''J--l> »'KRS<)NAU IWKTICrLARS ARK TRIK To THK
Ithsroi< MY KN()\Vl.Kn<*.K AND IJKI.IKK
Former or
Usual Residence
When was disease contracted,
If not at place of death?
How lonq at
Place of Death ?
Transients,
Days
Ml
(.\<lclress
(Address
N. B. Every Item o? information should be carefully nuppiled. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The '♦Special Information" f«r ••r.
«ons dylnft away from home should be &!ven in evory instance.
V'
li'
. .41
I
1'.
M
â– w
> â–
1
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t
•t
V;
i
1
b.
i\
.1^
: I i.
!l
|,-V,J-!.;(i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
:it,! .,f Hr.lltll I- X<' I- •t>'^^^''-; li.V I' C,
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/)((/(' Fi /('(/, (X.^v/cyL\^ n
lf)0^
Registered Js'*o,
1
Deputy Health Officer
DEPARTMENT OF PUBLIC ilEALTH-City and County of San Francisco
dcrtificatc of ©catb
( U. %. StnnI>arC> )
^ ^ J?
%
PLACE OF DEATH: — County ofvJ/O/w OAXXy^xccvtCt City of ^<^>v 0 Axx^ yv<^a.xl ti^
IVo
.5t m
OJ
CK-
|\AA/X.
St.;
Dist.; bet.
and
f ir dcatA occurs a\mav from USUAL RES I DE NCE ci VE facts called for under "special information' \
V IF DC^TH occurred IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
SIX
PERSONAL AND STATIST
FULL NAME
ICAL PARTICULARS
^jy\f>(\KX> vJLlo
(rirbny^v/)
aJU,
M-
i» \ 1 1-: < »i r.iK rn
\t.i-;
Y,ai
1
M,niths
(Vcar)
H
lilKl'lIl'I. Ai'l-:
'Slate or Comitrv
\.\Mi: oi
!• \'i"iii;r
lUKIill'I.Ar
oi- i-Ariii'
state or (."ounli V
Ux\A.^ULdL
MEDICAL CERTIFICATE OF DEATH
DATH (»I- Dl.ATll r^
^Mdiitli) ,r (Day) (Vc-ai)
1 in':ki{l!V Cl'iRTll-V, That I attcu.k'.l (Iccvascd from
HW-U 1 t up H to CLuwQ_ L& i^o H
lliat I last saw li-A,^' alive on LA^Ays^ 1.1 loo 'V
and that .k-ath occurred, on the date stated' above, at '^
U. .^L TIk- CAlSTv ()!• I)i:.\TII was as follows:
DIKATIOX
CONTUIIUTORV
) 'cars
MAn)i:N N\Mi: (^ a /Tv
oi- M()Tiii;k L 1| [V
HKiiii'i.Ar}-; X
»i Morm-k A y
State or eoiiiitryl Ij '
HI
OCC
Years
Mo)ilhs
.drouth:
'1
^
Diiys
Hours
1 )r RATIO N
(SIGNED) Ll>Ctivuav ^; . vi^ v.^^v^o^
\X<^X>, IL rcjo'i (Address) BtrXHlxX.'
SPECIAL Information only for Hospitals, Institutions, Transients
or Recent Residents, and persons dying away from liome.
Days Hours
K^^u M.D.
0 dl'ft-dixi..
t. 0 ^ M J Ut^aXcvM U. V . piare of Deatfi ?
f\r>'iffif ill S,ni /'i ,!ih /m;i \[ )>-,// c
^rniiflf
n,i\s
'''"',';,>'!' '^■'•" ^'l'\!"l-I> PKKSOXM, I'VKTU-fl.ARS A R !■: TRrK T< » Till-
l.l-.sl OI- MY KNOW I, i: DC, H AND HHUIKF
(1
b<j±^\niy(uX
V/>A^
'\^l.!r.-.s C>C)'i
/(n'>'VJL\x/
Lwa
Former or
L'siial Residence
Wfjen was disease contracted, ^ ^
If not at place of death?
Days
n.ACH ())• HrklAI. OR R}:mo\AI,
DA'I"K<)!" IliHiAr. or KIvMoxaj,
TQOH
(Address
' . B. F.very item oil inltormation should be carefully supplied. AGB should be stnted EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The •'Special Information" for D«r-
sons dym^ away from home should be feiven in every instance.
f
m
I
41
11
1
I
Â¥ J
te"
I
' ♦
m
r
1-1 !
«!
^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
H,,:,T-.l ..f II.:ilth ^ V Sn m ^-F^^iiir*' '"'^ 1' '
dLcr\^A.o iiLa>v. Deputy Health Officer
Registered J\^o.
1054
}
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
{ TX, S. 5tan^ar^ )
PLACE OF DEATH: — County of 0 /CU^rv J/UXTL/CXaC^j City of 0/CL/Tu oAXXy-v vc.c<teo
NoAt'i ^J(xYVyJlOx't\>A-0.' St.; '^ Dist.; bet. 2);v<L and H t4\;
(IF DE«TH OCCURS AW«V FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" N
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME OcLcAvKVv<ij 0 .>\x>djAx<:^ UJLrux.lvcv>>v
PERSONAL AND STATISTICAL PARTICULARS
OLv
DA'l'i: <»! KIK 111
V . 1.
\
\
^\^
â– â– u
yavv-
I);iv)
<V(;ir)
4t^
b
1/ ' v.-
X^
-IN' !.i: MARlvIi;!).
\\'!i)< t\\i-:i> OR i)i\'(>ri'):j)
W'l it' in >.<)ri;il (l<-ii.rnati' m )
lUKTII IM, \rv
(Stilt. ■.! '•..:;;;lt \
J-ATHJ-.R \()n
MEDICAL CERTIFICATE OF DEATH
1 1 ATI". • »!• i>i;a TH
n
^kxAjc
Kx.O
w.Cuy'Y^-
lURTHlM.ArH
«)i" I \ riiHK
' St.Mtt (.1 ('> ^niitr\ '
maiiii:n \ami-.
HlRTllI'LA'/l-:
nl' MoTHKR
'Slate or roiuiti \
OCCT
f<?cA
(Month) (\ (Day) (Year)
I lli;ki;HV Cl-RTIl'V, TliMl I attt'ii.UMl ileceased from
VlrVo^ Xl 190S t.) Caa^q. 1(q 190 h
tli.'it I last ^a\v h *w .>v alive on nJ^A^v-O. \^ 190 'S
ami that <U'ath occurred, on the date sta1e<l above, at v- o5^
LL M. The CATS]-: Ol" I)1:ATII was as follows:
DlRA'noN )'rais Mo>i//is;Wi'X fhiys Hours
CONTRIIUTORV
1)1 RATION
/?)
Years
Mo)ith>
Pavs
(SIGNED) ^vK.^'^l.(J)XV.vcLt
LAxvQ \'-l T(,oH (Address) 1^^ 0 CrUl
Hours
M.D.
t»v
SPECIAL INFORMATION only tor llospitdh, Inslitiitions, Transients,
or Rrrent Rrsidriits, and persons dying away from home.
AV.,',,V(/ /;/ V,;)' / / ,;;-
1/ -////.
/ ',,â– 1
Tin-. AHovK ST \'i'i:n ckkx' »n a 1. y\ ki-ut i. \ k-^ a k 1: i'r i 1: r< > rii i-;
m:sT Ol' Mv KNiiw i.i:i)(,i.; AM) in:i,n;i-
e
Former or
Usual Residence
When was disease confrarted,
If not at plare of death ?
HoH lonq at
Plare of Death ?
Ddvs
ri,A(."i-: <ir iukiai, ok i.;i;M< i\ai.
T90H
KAIl-.o;" in KiAi. or R1-:M()\m^
rNi»i:R'rAKi:R 0 '0^/^vvt>rvjL^u \>J -K,.<>-'<V
(Address
IS. B. Kvery item of informiition •thoiild be cjii'cfullj MupplicMl. A(IF. «ho;iltl be stated r.XACTLY. PHYSICIANS should
state CAUSE OP DEATH in pljiin terms, thnt it mjiy be properly clossifieil. The ''Special Information" for per-
son* dyin^ away from home should be (^iven in every instance.
? V.
w^
fH
I â– ' t
fill
1 ''
I;
WW
â– ' '1.
â– â– \
.V
I ^ *
.1'
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
llr,:,!,l ,.f II, , lit!) !â– â– No ;- "?-r\ia^;. V.SiV Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
\l
IfJOH
Date Filed , LI.a^v.<xva.<iAJ
X<iAAA.^ \kjxy^. Deputy Health Officer
llc^istei'od Ko.
105^
^
DEPARTMENT OF PUBLIC nEALTH=City and County of San Francisco
Certificate of Beatb
{ XI. 5. Stanc>arC> )
PLACE OF DEATH: — County ofCJ/OAV J ;uX/>\/OUlCC) City of C3/ayru 0 AxXox/Ci^vA^o
NoA^D'i Ulxor\\X/^vtAAA-tX' St.; ?^ Dist.;bet. 2)Kxi> and \XX-\3
(ir DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME C<iAA^<xvcl.' 0 AX<LiLA.vc4^ UJlruxJ['VCL/>'>v
PERSONAL AND STATISTICAL PARTICULARS
oJU
C<U,uK
Lixvlji
A 11. 1 11 iiiK rii
AT, i-;
4?>
!V,;
t
ai
m.-iv)
I/..////"
MEDICAL CERTIFICATE OF DEATH
DAIl", < M" I)1:A'1'1I
n
(Day) (Year)
(Month)
I ni;ki:i?V CI^RTIFV, That I attendod deceased from
vTyvoA^ x^ 190H to Ow^.^*^^ lb
â– xt
l\iy.
-'INt.I.i:. MARkli:!),
WNioWKI) OK I)[V< »Kvi;i)
Wiiti ill <i)ci;(l (li>.ii.']i;it i' 111 )
vXMI' OI-Wn
•atiii:k ^Qil
luk rniM.AiM-:
'Stall- ur (.*oniitr\'
rV<xiva'>TV'
r.iK ini'LAO}-:
oi" i\rin--.K
St.Mtc 1)1 r.niiitrv
maii)i:n XAM1-:
ic)o H
and that di-ath oceiirred, on tlie date staled above, at \. oS"
lliat I hist saw h '^ >>\ aHve on
a
NI. The CAISI' OI" Dl-ATH was as folhnvs
1)1 KA'I'ION Years MouthsW'X Days
CONTKIIUTORV
Hours
>..• MCTMKK (T\
V^^'
V>Y\XX/'W
iiiK rii I'l.A'/i-:
ol' MoTlIKK
' Siatf or eounti \
\
:cii>ATi()x (T^ . K
I >r RATION ^ }V<7r.v
Mouths Days Hours
Signed) OV.VIil Ob. xyx^^^xLt) m.d.
i
SPECIAL Information onl> for llospitdls, institutions, Transients,
or Rerenf Residents, and persons dying away from home.
AV' • uU'd / II San I'l i! '
) 'I'd I
^l.:lfh^
h.
Tin". AIIOVK S'i'A'ri-I) i'HKsi »NAI. I'A RT IT r I. A R S .VRl". TKri-: T< ) I'll )•;
m:sT oi- Mv K. Now 1,1. 1 x,}-: .wd iu:i.ii;k
k\^^
' \<l(lr<-ss
Former or
Usual Residence
When Has disease contracted,
If not at place of death ?
Hov^ lonq at
Place of Death ?
Days
I'l.A*.!-: (>I lURIAI, OR Rl.MoWM,
n\ri:.)f HrKi.Ai, or KKM<)\AI,
T90H
(AcKltfvs
N. B..
-F.vepy item of information should he cin'ofuMy supplied. AdF. Hhoiild he stated FiXACTLY. PHYSICIANS should
state CAUSE OP DEATH in plain terms, that it may he properly classified. The "Special Information" for par-
sons dyinjj away from home should he ^iven in every instance.
â– H
I ;)i
* .!,
I't
J
' i\
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
It.Mid ..f Hciltli ]■' No. 1=; t-^«-«.->, H<<t J' CV)
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
mp
Dff/e Filcfl ,
C\..V^^>^->s^>0
li
190\
Regi.stcred J\''o.
i 055
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( XX. S. StanDarD )
PLACE OF DEATH: — County ofC)/0^\;OXxX^rUMw^LeoCity of O/CLAV O AXXAOX^CA. a^
No.
io^l
<^^\y'y^<Xj
H
1
^tl-
St.; "^ Dist.; bet. I /V^^TO and C) A^A\j
ilDENCEGIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
VMlcJu U)J\Aix
I) A ri'", ( 11 IlIKTII
(Mr)Mtir!
AC.H
S'l
)V,
ID.MVI
.1/.-;////.
I â– /car)
/',n. s
MEDICAL CERTIFICATE OF DEATH
DATJi ()1- DlvXTH /O
(MoiiDi) r (Day)
I IIl{RI-;nV CivRTlFV, That I atkii. led deceased from
- to ~— — T-rTrrr-rrrrr
(Year)
1 90
SINr.l.K. MAkUIl'.I)
\\II)<>\VJ-:i) OR I)I\<)K»i;i) ^
'W'litriii social ilt^itMiatioii )
Mi
lUkTui'UAri.;
'Statf or ComitrN I
NAMJ- 01
i"A'nii:K
Hik rni'i.ACH
01 I'AIHF.k
' "^tatc ()T- Coiiiitrv
MAIOllX NAM)'
01 MOTHJ-.K
liikrin-LAci-:
oi" MOTHHK
(State or Coimtrv)
tliat T last saw h ^^ alive 011
190
T90
and that death (jcourred, 011 the date stated aliove, at â–
~_ M. The CArSP: ()1- 1)I<:aTII n-^is as follows:
1)1' RATION }'rars
CONTRIHUTORY
Months
Days
Hours
oceriv\Ti(,x ri) , ::? 0
DI'RATIOX Vrars Mouths Days
(SIGNED) J. \Jj.U).XJLcL/>v<3L U\^VA
l^ 190H (Address) LvurvMA-^ U
//ours
Jih) M.D.
Special Information only for Hospitdis. insdiufi
or Rpunf Residents, dnd persons dying away froin home.
Rf'tdrd ill Sail /'i <; in m-,i
)",„
M..iith-
/',
Former or
UsudI Residence
When was disease contracted,
I 'f not at place of deatti ?
Hovv long at
Place of Death ?
nS, Transients,
Days
•nii: XHovr: s-|-\ti:i) i-kksonai, I'VRiicri.Aks Akj-: rkti- i-o tin-
Hl.SI Ol- MV K N( I W 1,1: 1 )(•.;;; AND \W.\,\V,\-
(IiifnMiiant \; iVv^
'\.Mrc.^ bOl \l rLc/>V>VOuOt)
DAI'Hof P.riuAi. «.r RJCMOVAJ,
%
I'l.Arj-; Ol- iMRiAi, OR ki;m()\ai,
rNDl-.KTAKKK (fvD . J- OxaJKA/^^Co
T90S
fAdflrt-ss
N. B.-
-Hvery item of information HhouIJ be cnrefully «uppliecl. AdR HhouftI be stated EXACTLY. PHYSICIANS should
state CAUSn OF DFATH in pli.in terms, that it may be properly claHsified. The "Special Information" for o.r-
Rons clyin^ away from home should be ^iven in every instance.
!' ll
1
i
141
I
i
1i
itJii
1:
ill!
4'
ij
i
.1 >
I,
r
H
/
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
lioilKl nf lit ;il|)i I" Xo. 1
'*^^'*?
S^'}-.*-. HvSiI' Co
Dfffc n/rd , LLL^>L..oQ:fc
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
\%
I!) OH
L^
Reglstei'ed J\^o.
I ^^n
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( "KX. S. Staii&ar? )
PLACE OF DEATH: — County ofVJ/Ouvu ^J/u<X/>vcA^a/cuo City of CJ-CL/tu J A/Cl/>a./Ca^<^o
No. UT Uldo St.; X Dist.; bet. XaAJkA./>^ and VJ Cr(J\
( '" °"'f^l°ccuRs Aw*v rpoM USUAL RESIDENCE give facts called for under "special information- \
\ IF DEAjTH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER )
FULL NAME
'^:^:\.>
>i:\
PERSONAL AND STATISTICAL PARTICULARS
(^ ft , ^'-I.-'K
^'^r^XxXjb
I> \ I !•: < >!• UlK'llI
\f. !â– ;
iMoiitli) /|
) V(/)
lb
(Day)
Mouth ^
fVcrirl
fhn
^iNt.i.K. M.\kuii;i)
wiiM >\\ i;i) OK i)[\( »R»i-: 1)
'Writ.' ill M)<-i;ii .K sij,'ti;iti..ii)
HiKriiiM, \ri-:
'Statf or Coiiiili vi
NAMl-; ()!•
iATin:R
HIR rill'I.ACK
'>!• l-ATMIvR
iStiitf or (.â– ()initr\
MAII)i:X NAMl-
<>I' M()TlIi:k
HiR rin-i.Ari-;
•»i- M(»tii);k
'Sl:itc or Country)
(3f (1
MEDICAL CERTIFICATE OF DEATH
DATK OF I)1-:aTII r^
^^^^-^-^-o n. j^o'\
f^""t'i^ (J (Day) (Vcar)
I HHRIUiV CJ-RTIFV, That I attended (IcccaseTrfr^oni
'^ 190I to ^^-^-^ n 190 S
tliat I last" saw h -r^^.' alive on LLl.^ H t^q M
and that death occurred, on the date stated above, at S.3 0
'Ip^r- '^*li^' CAISIC (.)!• I)|{ATn was as foil.
)ws :
CS^jtxXA)
K.^Y\^
J? Oj)
1)1 RATION Years
Mofitin Days
I /ours
Dl'RATIOX
{ Signed )
)'cars
out /is
OCCri'ATlON
AW^ /;/ ,V,7„ rt,!)t, !-r,, — )■,,;/- ^ M.^iitli, \ 1
Davs
-\^<J^Jf^
//on
rs
M.D.
f ^^?'fi'-."^f°"'^'^'^'ON only for Hospitals, Insfifufions, Transients
or Recent Residents, and persons dying away from fiome.
'""'.;, ^J-r' Vw •';'!". V'"'"" ''»'-'<^<'NM.l'\RTICri,ARSARI-. TRCK To TIM-
iii-,si oi- \\\ K>:<»\\i):i)c, K \\i) mi-:mi:f
(lMf');inrint
Former or
Usual Residence
Wtien was disease contracted,
If not at place of deatti ?
How lonq at
Place of Death?
Days
' \'l.lr.
loO'l
^
''''•\iii'l,*''"J^'''^'^'''»l< 1<i;m.,VAI. I)ATK,,f n,K,,,. or RKMOVAI,
INI
)i.KTAKKR LoJUJUrVv"y^A/Ou Uw^vAxilo Co
"' ''■Itrt7c'l\rSF^OP nTrTH" "^^^^ '^^ carefuny suppliecl. AGB nhould be ntntecl BXACTLY. PHYSICIANS «houId
•in. civfni „ ^'^f "^A^" '" •»'"'" f*^'-'"«. th«t it may be properly cla««iiiied. The "Special Information" for per-
sons cl>ini away from home Hhoiild be feiven in every instance.
t
1 1
li'
\\\
TA
PS
i
i
I
/
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
*â– !!?>'
)t";it(l of H<;ilth »•■Vo K 'f-si: ."*./'"'♦ Mi"^ 1' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Ihffr F/7rf/, [X^^x^yu^ \l mO'i
Begistcred J\^o,
< 057
,<rVA.-^--o
>^{
N
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDcatb
( Xk. S. Stanear^ )
PLACE OF DEATH: — County ofOcL^^; vj;LCU\vCAXLao City of d/O/ru 0 ^L/O/vurx^^ e-t
o. \^'KaJLc\AXa\^
(
St.;
IF DEATH OCCURS AWA
Dist.; bet.
iUAL RESIDENCE GIVE facts called for under "special
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREE
"and
FULL NAME
lAL INFORMATION" \
T AND NUMBER. /
S !•: \
PERSONAL AND STATISTICAL PARTICULARS
DAii-; (ti liiKTn
\'.i-;
1
U
null I
) Id )
5-
'I):tv)
.1 /.->////>
\x
(W ,11
/',/]
HINCI,!- M \ K k I i;i).
Wiitciii x.iiial (1( si(,^i);(tioii )
x^y^
'St:i!' '.• ''nititrv'
N'AMl' <)1-
F \thi:k
lUR'IMIM.ACH
f)|- I-ATIIKK
'St;it> <)1 ("nnilliv)
maii));n xamk
of mothhk
niRTUI'r.AOF:
'>!•■MnTHI-,k
( suite or CduiiIi \ )
OCCrPATlON
[^ ] (J p |0
MEDICAL CERTIFICATE OF DEATH
datf: of DicATH r\
'^^-^^ n /(?r>H
( Mouth) J (Day) (Year)
m:KI';HV CI:rT]I'V, Tliat r atteM(k-<l deceased 7mm
l^ 190 H to LXm^ 11 KpC^
that I last saw h XV alive on CLlaXV H ^d 0\ icp H
atid that death oc(Mirred, on the date stated above, at 10-2)0
U. M. The CAISI^)!- 1)1-:.\TII uas as follows:
IM- RAT I ON Vrars \ Mouths H Days Hour,
CONTRIIU-TORV VIax^ccJLlW^ Ull
â– !OXX\jy:
Lt\r
I )r RATION S Vrars .mouuis
(SIGNED) It). J . Ijuxiji^UX
^^^^-^-^ n i()o'-\ (Ad.itvs>.) UI^JUl\Jt^\^ '()b(S4.lvt
Mouths Days Hours
M.D.
112:
^P^^^'f^L INFORMATION only for Hospitals. Institutions, Transients
or Recent Residents, dnd persons dying awdy fro.ti fjome.
â– > ) .
'./ /
lA. /////>
'" n,^ ",V^'^. ^''' XH' I » 1' F k ^. )\ \ 1 , 1- M< I I . • r I, \ K ^ A K F; T K I I-: T( . Til }■•
I'F.SI OF >,J^V KNOWI.l.Dt-,}.; AM) in- 1, 1 1 ; 1-
fii>f":"iriiit ds^-^rVLA^ VJj XxX>
former or [\ ^\ P 3 Hon long at
Isual Residence M kKaJSTYTsjO^ \JXXj pjace of Death ? P
was disease rontrarted, (v 0 (^ [)
at place of deaffi ? VJ CXJL^rywXK) LxXv
Days
When was
If not
.\J^
^'i'i'<'«'^ ^J X^>-^AJL\aXX) L<U(Jt^^OvOU^ L<
TQOH
I'I.AC|:oF MrJ<lAI. OK '<»-^'"VAI. I,An.:,.f p.rK.AK or KKMOVAI,
(Address 3 IH iD ' J <X>UuJl dl
I ndf;
N. B.-
-Kvery item of information hHouIcI be cnrefully Rupplie.l. AGR «houltl be stated F.XACTLY. PHYSICIANS should
state CAII8E OF DEATH In plain terms, that it may be properly classified. The "Special Information" for o.r-
Rons dymft away from home should be iliven in as^vy instance.
;r
i T i
•t
) ']
11
/
I
i.4
'^
mm
II i.
1^
4
1
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
H-Mi.l ..f Hiriltli I- No. !«; ■*-^''ra^.;, lK<;tl'Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Deputy Health Officer
Bogi\si('i'0(l ^^r;.
lOi
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of Beatb
PLACE OF DEATH: — County of vJCL^>\.) O^^vCl/^^/Caa^co City of O/Cla^ J AxXy->a.CA.<iXi c
St.; H Dist.; bet. db CK^J<XAydL> and 0 O-lA-tn-W
i AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" N
IRRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
No. 0 dlD .a,^.»vvxl'
FULL NAME
SI
PERSONAL AND STATISTICAL PARTICULARS
'!
DA II-: ol' lUKlll
.\^.\^.
JJxVAX
/UCr\Ary\;
MEDICAL CERTIFICATE OF DEATH
DATH OI" I)i;A'i II ^-^
(Month) (V (I)av)
IH
il):i\ I
) III I s
Mnlilliy
a
/),/
SINC.I.i:, MAKRIl-l).
WIDoWKl) OK DIVoKaIJ)
iWritcin social rltsit'iiiiti'iii)
d
HIRTHl'I.ACK
' -^ritc or (."oiii'.trv'
NAM}; or
I-ATIII-R
niRTMl'!. AiK
Of I'ArnKR
fSlatf Ml rouiitrv)
MAIDI-.N NAMl-;
<>i M<»rm;R
IMRIIII'UACI-:
Ol- MorilKR
(State or Countiv)
occri'A rioN
f\t' idrd ill .S\ni I'l ,1)1. f ,-,i
XX/^X) O ^vXX^VVX^A^^CL/C^
(Year)
I IN'RIvHY Cl-RTIFV, That I attcii.led deceased Yroiii
'J-^-^ IH 190H to CLaw^ 1.H 1^4
that I last saw h :^*V alive on LLa^/Ol 1 H Kp H
and that death occurred, on the date stated above, at 1^
^ -M. The CArSl<: OI' niCATII was as follows:
r f I
DCRAriO.X }'tU7rs
C()NTRII5rT()RY
IMontln;
Days (0 Hours
\y\Jb
DI-RATIOX Years Mouths Days
(SIGNED) lO. d dvJjLx
UoC\^^ iS'iQoH (Ad.lress) ^ 3) ( ()b 0-Uj<t\xi^ Ot
PEC^AL IN
Hours
M.D.
?''^9^'S'- Information only for Hospitals, InstituNons, Transients
or Recent Residents, and persons dying away froni fiome. '
) I'll I >
"" ^r..||fh^ 1^ //,;
THr. AHOVK SI-ATI-I) PHRsoVAi. 1' \ RTirr l.ARS ARi; TRD-: To TIN-
ifhsi OI- Mv KNo\\ij:i>(-,h- AM) in-:Mi-:i--
Former or
L'sual Residence
When was disease contracted,
If not at place of dcatfi ?
flow lonq at
Place of Oeatfj ?
Days
f Iiif'i-iiiaut
U). a
M.d.lif^-;
S^l 'db Cru^KXVdL cjt
ri.ACK OK IirRIAI. OR RI-:moVM, j I)\Tl-:.,f liiKiAi. ,„ RHMOVAI,
rNi)i-;R'rAivi-:R
^^cMrrs';
SbT^- l^
^' "• ^'^^^y 'tern of informntSon should be cnrefully supplied. AGB should be «tfited EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may he properly classified. The "Special Information" for D«r-
8on« dyinft away from home should be jiiven in every instance.
\
f
I ;'
!;
«•;!
> t
.1.
â– f
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
V.r.-jv] .f !!' ii'th- I" No ••• "^"'i.^?/^*' HS.I' C-,
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Bogisfd'od J\^o.
' 059
cLci-ccvo kju\>-\j Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of jDeath
( "U. 5. Stan^arC> )
J? (?T^ A %
PLACE OF DEATH: — County ofC'CL^^- 0/VCX^vC^si C^City of C)<X/>v O.h^CU^vCc^c^
Ne. 0.\JL^VcJk) ()bcHtix\l<x( St.; Dist.; bet. and
(ir Dt»TH OCCURS «W*V TROM USUAL R E S I D E N C E G I V E facts called for under "special INrORMATION " "\
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME 0.t>viXcvcL«-
-)
•1 A
PERSONAL AND STATISTICAL PARTICULARS
i> \ ri- < ii r.ik Til
" 1
15-
'D.-iv*
\' .1',
3.^
/'(M.>
^OAX
nil;-'-:i;M v.-j-
F'ATIU: R
HIk rui'i.ArH
'»i- fathi:r
'^' iti or i,"<)ni)tr\' '
maii>i:n NAMi-:
or MoTUHR
iJikiin-i. \<i-;
OF- MttTHi:K
! Stall- <jr (.'<iinui
' »■> I lAlIoN
MEDICAL CERTIFICATE OF DEATH
' Ml null > [\ (Day)
I HI-:RI-:iiV C1;RTIFV. That I atUMi.lc.l .IcHiMse.l from
VvOLvv_ '^ looH to LLum3i_ l"^
(Year)
â– y ^ 190H to ywA^^s^ It KjoH
that I last saw h -»w/u alive oil v^^A-a^CL 'I
ajid that (U>ath occurred, cm the datt- stated above, at io
(X M. The CAISK C)l- 1)I-;AT!I
was as follow^
I ) I â– R A r I < ) N
}'<•(/;.?
CONTRIIUToRV O-r^^
M (tilths Pays
I/oitrs
DTRATloN
(Signed )
)'i'ars
Cb. LIa1..<^X3.
n
Xj^X) ij . \j
kVidf,! in S,ni I'iaii< '^»•'> ,JL Vj
?.
v^A^^o il> ic)oH rAddris<) i£^2) UxxXXx
:3JJlL22_L_
:iAL iNFORi
Pays
Hours
M.D.
/'.'l.
rni' AHovK ST \ri:ii rKRSiiN \i. !■\K ihii \k^ \ki- trii- ri • I'ni-'
in-;sT •»! 'iJV KN<i\\I,l-:i)r. h AND lU.l.lI'.i
(It. forma nt Obj2^'>'^VM, ^ CC^W-aJL^A^
0 (p a
4
\.Mv.
SPECIi^kL Information onU tor Hospitdls, institutions'! Transients,
or Recent Residents, dnd persons dying av»a\ from home.
former or "^rJ^^T^?^^ ^'^^ ,t; fioH long at
Lisual Residence vj <xJk>v/o^/-i^cxA^ ^-a-. place of Deatfi? H I Oavs
When Has disease contracted,
If not at place of death ?
rLACl-: ())• lUKIAI, Ok K1-:Mi i\AJ,
CnLu Uv
^r^^
I)Arjj:(>f 15! i-i.Ai, (,r Rl-:Mn\Ai,
^"^ I90M
0
(Ad.
•^^ ^' f"'vepy item olf infurmHtion should h.- cnrcfully siipplle«l. AGK Hhould be Htateil F.XACTLY. PHYSICIANS Hhouid
•tHtc CAUSE OF DEATH in phiin terms, that it may be properly classified. The "Special Information" for p«r-
Bon* dyln^ away from home should be ftiven in «very instance.
If
â– 1
'I;
•:U.]
J .:
i k \''
t I
U
; ft
11-
Ml.
Mi
;• t
( r
it I
I I
• t
^M
r
I \.
m
fr'^r-^,'.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Hm:M(1 of II( :ilth I' V<
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/)f(/r rilrd, LUaXX^^aaJj 1%
lOO'i
Jlrgi.s/crcd jV(h
1 fi(\0
tj-\A.A^
^
^fj^ty Hcahn (jffi
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 5)eatb
( U. S. 5tnn^nr^ )
^ (^ J?
%
PLACE OF DEATH: — County ofO/(Vru v) AXX/^x<>L4C(City ofO/CUOO; OAXX/YvedX^c
I^.
iiu X
^A.sLi\>0^<LiSt.;
~ Dist.; bet.
and
rt /' ir DEATH occunaTAWAv FROM USUAL RESIDENCE GIVE facts called for under "special i n formation-' 'X
J V 'P death occi^red in a hospital or institution give its name instead of street and number. /
FULL NAME
.^w^
Uv^Crur
f
Utu
PERSONAL AND STATISTICAL PARTICULARS
--I'.X
I) A ri'. < »i HI Kill
^' . }â– :
M..Ath)
,aJu
UJJvctji
Avi
51 .,.., H
il);iv)
M.'utli
' '\'f,\\
MEDICAL CERTIFICATE OF DEATH
DA'ri". nl- Di: \ III
n
(D.iv)
11
/',
I vs
\\ !!« »\\i<: I) ( )« iti\i )Rri: 1)
' W'l it' ill -i.( ial (!(sij.Miiit i.ui )
luk riii'i, \<^}'
'Mill' l)T I Mllllt I \
|'ATiii;k
HIRTHI'I.ACK
«>i- i-ATm:K
'Sl.itc oi Coiiiiti \^
MAII)i:\ \AMl-.
"!■M(»rin:k
inKi'iiiM.An-:
<>l- Mit'llll-.K
'-0
I Hi'RI'lJV CI'IKTII'V; That I .iltci.U.l .lc«xasf,l fm,,,
IvaXu ^0 up^\ to CX^-vq.
tliat I last saw li ^'^ ' > > alive on
(Month)
up\
ami that diatli occuircMl, on tlu- datr stated above, at S" v) 0
M. 'Ihe CAISI.; OI' I)i: \|-il was as follows
, ;n . •" • ' '"^ v.Yi vii, wi I'l. \iii \\^is as I OIK
A^A^-VN.
1
.'Y^^J L^uO-U.rlx^
A)
ct
1)1 RA'i'lON Years
CON'i'Kir.rTokV
}'i'll IS
Months
\l
Pays
J/oin
f\'f!lll'<! Ill Will I I ,1 II, I -I'll »■)V,M» "^
DIRATION
(Signed) UJ. Xd . L<r^\X_
VA.\^txr; i()o'\ (Addn-^s) UJLy\'ya.Iv^
dPal Infor
Mon/Zis /hns
//ours
M.D.
SPECmL Information "nly for llospildls, Instilulions, Irdnsients
or Rerent Residents, ,ind persons dyini) dway from fiome, '
Former or
llsudi Residence
?
How long df
f'Idre of Oedfh ?
1/,.;//'//
/>.n
llir A)|()VK ST\ Til) I'KKSONAI, l'\l< IH TI.AKS AKl! VRl }â– Tn nil-
lU.Sl (»|. MV KNUA\|,l,I)C.|.: AM) i!i;i,ii:i-
Onf>j;iit;iilt
< X'ldicss
Wfien was disease ronlrd(fed,
If not at pidfe of deatli ?
Days
<i \^^C.
I'l.Ari- ()i- lURiAi. Ok ki:M(.v\i, I datk,;- hiiuai (.1 kj:muv\u
0 h) Op ^. %" ^
MMKM
N. K. Kvery item of infoniiHtion Khotilcl be cnrefully supplied. AGK should be stjited KXACTLY. PHYSICIANS should
«tatc CAlISi: OP DliA TH in plnin terms, that it may be properly classified. The "Special Information" for par-
sons dyinii away from home should be feivcn in every instance.
M
\ •
if
.1 .
w<-y
"I
» i
"
I :
^.
m
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
t)*""^"*.
j;n;,lrl of II. ;iltll I" N'o. H t-- » --i) ){& P ».
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dfffc Fi /('(/,
cLcrOu^
\i
WOH
Reo'istered J\i''n.
^ OG 1
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeath
SI ^ J?
^
PLACE OF DEATH: — County ofCJ/CL/-^ 0A^<X>vc.c4.C( City of 0 Cu v\j U AXX/'VX'C^^ C
o
ncSRIpSIl^
â– OM^'^A^^Cj^*^.'
St.; H Dist.;bet. (o
\\)
.-It!
and I Ot'
(IF DtATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V C FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME
a
X-^rV
si;\
PERSONAL AND STATISTICAL PARTICULARS
!).\ 1 ! Ml Hi Kill
\i
JJJx^LiL;
<X<.<^r-
MEDICAL CERTIFICATE OF DEATH
DATK ol' 1)i;ath
|\!Mntli
^
Ob r,„..
li
II):ivl
M »/.'//•
\%
(Momli) rt (Dayl (Yrnr^
I m:Ri;r.V CIvRTIFV, That I attcMidcl (Iciv.isc.l from
a^
/),.' 1
<I\i'.l.l" MARRIl".!)
WIIx >\Vl'It OK I>I\'( iKT I'D
(\\'ii!i in s<n.-i;i] i!< v'<.Mi.it imi )
lukruri, Ai'i"
'Stilt I (ir rrnint I \
1 H
NAM)-: or
I'Aiiii:k
lUKIH IM. \iV.
«)! lAriM'K
(St.-lti- (It I'dUIlt I \
^M II li.N \ \M I
<'i Mi>rni';K
I'.iRiin-i.ArH
oi' Moi'IIlvU
'Stale nr C'ouiitrvl
.0^<i
u
XXX
I I I I , I\ I , 1 1
190 H t
\^p\
OLCcr
V>U
lxXv>
that I last saw h I- i>\ alive on \J^^CQ ^ 11 190'!
and that <Uath occiirrcMl, 011 the datr "^tatetl ahove, at H
VJ ^\. The CAl^h; ()!• 1)1<;.\TH wa>^ as follows:
1)1 RATION )-fars Man //is /hfvs J lours
CONTRir.rTORV
1)1 RAT ION Years
( Signed ) J. <i M
0 XOL v^ v<i.yUt^.>
Months Pays Hours
u^rw-w^x^ M.D.
Lww^Q ll loo'i (A.l.lress) I I 1 6 H iXcuJkjob
It
SPEOIAL Information only lor Hospitals, Institutions, Transients,
or Recent Residents, and persons dyinij away from home.
M.nilf,'
IK!\
I III' AIJOVI-: sr \ 111) I'KKSONAI, I'AKriCl I.AKS AKl' rkri-- )•( > Til F
luvsr oi- Mv KNOW i.i-.Dc. H AM) in-:i,ii:i-
Former or
Isufll Residence
Wfien Has disease contracted,
If not at place of deatfi ?
Hovv long at
Place of OeatI) ?
Days
I NDl.K lAKl-K LvV\aXC<X V,^^A V-C^_XA^V'CCV\jLV/i
l)\ri^)! Mi HiAi (.1 KI'iMOVAI,
'A.i.Ilr
N. R.-
^■i- il—i
-F.vepy item of informHtion should b.- cnret'ully supplied. AdK should be stated fiXACTLY. PHYSICIANS Hhould
state CAUSr: or DTATM in plain terms, that it may be pr<»perly classified. The "Special Information" for par-
sons dyin^ awny from home should be J^iven in every instance.
J
I'M
J I
m
1^
i
!!
:
4*
m
• pi
I
f ?
â– m^^^
VcJ
1
i
i
<
M
â– w
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
*\>''*^%f
!!,.an! of ll< ;t!lli l" Vo. i '^ '^'t'^^jr^ "'"^ '" ^
REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
mmmmmmmmmmmm
I )((((' Filed ,
oUcrLx^Vw^
A
ii)()\
ItcgLslcrcd J\i'o.
1 0G2
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of IDeatb
( "a. 5. Stan^ari) )
PLACE OF DEATH: — County ofO/Oy-vx' ^Lh.XX/>^,/Ot^x:.cCity of ^'^^>v J /ucx^ x c>Aw<ixt
o
1
'Xa\j
'No.'XVX dJlXv/VAXvCcT^v \X\>A} St.; 5 Dist.; bet. IS XA\^ and lO
(ir ttATH OcAuBS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' ' \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
tl
FULL NAME
M ]\<x\^^.A^^ db /Cu'^vfc
PERSONAL AND STATISTICAL PARTICULARS
Ctx
:> \ I i: tu- I'.iK III
\<", K
(k.
lie
) '•(/; -
5^
3.5
iDayl
,1 /.;/,'//>
(Viar)
MEDICAL CERTIFICATE OF DEATH
DATli »>I I)I;ATH
(I)ny)
CL
9.3)
n,!
SI NT. I.I', MAKKIi:!)
\VII)( iWKI) OK I»:\i (l-Ti:!)
iWiit in â– ^uriiil dt sii.' n.it ii >ii )
IMK'PHIM.ArK
fSt.'itt or Cmniti \ »
iATin:R
I'.IRTHIM.ACK
<)I" I AIMIvR
istatf or (."'nititrv)
M\ii>i:\ Nwii;
• >i' m<>|-|ii;k
lUK rniM,Ai'j-;
<>l- MM'riN-'.K
< Slatf or (,"oujitr\ >
occn-A Tlox
I'Montlii i'l"
1 IIliRl'HV Cl.kril'V, That I attLMi.lfd (IcM'c-asLMl from
(Year)
190 '\ to vXw<3L n KpH
tlial I last saw h -^J^' alive on vA-VvXV ^1 H/D H
atul that iliath ori-tiritMl, on tht- tlatc statt'd ahovo, at O v> 0
V M Thi' CAISI' ()!• I)!-:aTI1 wa-^ as follows:
>LX/CV/vvfc -^^-^dX
I )r RATION Yrars Months 10 Days //out
C()NTRii;rT()kV
Ol>
t'>r\^>^'
Vf- ii/rif in S',n,' I'l ttvi i^ri) \
A'
)>,,•
^ \J.>,>lh<
I'
DC RATION )\'ars Months /\ivs //ours
iNED) M iIolW \, d/Ou^vvJk.t4u M.D.
l^t r()0^( (Address) 2.(0 S C)/CV>v VxXAXcy^vXv-C
(SIGI
SPECIAL INFORMATION only for Hospitals, Instifutions, Transients,
or Rerent Residents, and persons dying away from liomc.
liii: AH()\ K sr \i"i:i) i'Kksonai. iv\Ki"irri, aks aki- rKn-: ro tmi':
lllCST ()!• MY KN()WI,i:i)(",H AND lUvI.IllK
'Iiifo-niMiit
X'W'
yVDoJvfc 1-cxjUkjtX)
Former or
Usual Residence
When was disease rontracted,
If not at place of death?
How lonq at
Place of Death ?
Days
ri.ACK ()!â– â– niKIAI, OK KI:M( t\AI,
DAI^of !?i KiAi, f)i HHMOVAI,
^0 T90H
(Address iH^'i \MU.^U<LA.'Xrv\ 3t
N. B. Cvery item f»** inlfor'niation uhoultl be cnrefully supplied. A(]B Khoiild be stilted HXACTLY. PHYSICIAINS fthould
Htnte CAUSI: OI' DKA TM in plnin terms, that it mjiy be properly clussiltied. The "Special Information" ?gp pap-
song dyin^ awny (from homu should be i^iven in every instnnce.
"-1
'i
M
"If
(vtl
.^1
h
m
'I'
1 1
1
ni!
fi-:
•
III;
|l I
^1
I
l>i{
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
H":i!-1 of II. m1I)i I" No. i c, 1v'- â– !? ;i4i lUS: 1' C,
REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
Uuu^^cx^^^^.^ \h 700^
Deputy Health Officer
Registered J\^o.
^ £~\ -/'» ^-*. I
S? f p c s • jr
nafe tife(t , \x
DEPARTMENT Of PUBLIC HEALTIKity and County of San Francisco
Certificate of 2)eatb
PLACE OF DEATH: — County ofUcu^v. J>v<X/>x/Ouu;cCity of O'O-'W JAX3.-^v<M,.<i.<^<i
No.a^^'cU-p^vx^Urv IUk^ St.; 5 Dist.;bet. R ll and aoiJv
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
fl);(v)
Jx/^^'v<xAjl
DAii-: (II I'.ikiii
MEDICAL CERTIFICATE OF DEATH
DAll-; oi" DICATH
M..nth
\< .1-;
lb ;,....
5r
1A /////.
5.^
/',,â–
^IN<.l,l', M.\UKIi;i)
uii)(»\vi-;i) OR nivoi-TiM)
'Writ" ill ^<)ri;il (]( siviialioii)
I IK riii'i, Ai'i-;
'St;if< or Coiiiiti vl
\\\tl. I)!-
1 A riii.K
l'.IKT[H'I,A("H
<>l' lAI'IlIlK
'^t.iti or i'')uiiiiv
M\II)i:\ NAMI-
lUKIIIl'LACI-;
"I- M()Tmi.;k
'Stall- i.r Coiuitrx I
1)1"' ip \l-|n\
I HI-;RI-:I{V Ci:RTlI-V, That r attm.lol ,lccvaso<l fro,
190 1 t.) A^^ im h;oH
« I I I . IN i , I >
thai I last saw li â– ^J\-' aVwv 011
II
MiM that .Icath .H-ninxNl, n,, tin- .late stated above, at S 5 0
-^^''O'"" ^'/^^'' ^"' '^'-"^''''^ '''â– " ^^ follows:
-'^-^^-'tYvvt -^-A^diw*.
cr>v
A>Kx
cnx'i-Riur'j'oRv
/A;//
/,v
I) r RAT I ON
)'i'ai's
M(>)i//is
(SIGNED) m<XW Y 0<X.'yJi\Xu M.D.
.'VvJf-^
/'>avs
//ours
v-C
Rf^ulcl i)i Si/ii /'i in/, i-i ,1 \
)>.:;
C
or RccenI Residents, and persons dyinij ,iwdv from home. 'finsienrs,
!/../////>
/',,•
ifi.M (ii. MS K\()\yi,i;i)c,K AM) i!i:i,ii:i
'Info'iiiaiit
I
Former or
Usu.il Residence
When was disease rontrarted,
If not af plare of death ?
How long at
Plate of Death ?
Days
I'l.ACl-: OI- lUKlAI, (Ik Ri;M(t\\!,
fA(i,h-.s 3.4^^ (hx- "^
^^ ^^ I90H
I'AIUi.if Hi lUAl, 01 K »;M(»\ai^
N. B. fivcry itc
Htr/JVusr'of n^XT^^^^^ '"■^••"'^•'■""> -PP"-«. AGE «houI.l be Htnte.l HXACTLY. PHYSICIANS
sons civfni « f I '" ',"'" ''"'""' *''"* '* '""^ ''" pr.M-rly duHsh'iecI. The "Special InV'or„u.llo„- f
sons dyinft away from home should be 0,]ven in every instflnce.
fihould
for pur-
il
' »1
ill
f
^r
Ill
â– f
M
f .
f
>
WRITE PLAINLY WITH UNFADING INK —
Hoard of Ilialtli 1" No. i> *•« ; tsr 2i4 \\Si.\' Co
n
1 )((/(' riled , LLu^^^AA^ I?,
IfJO'i
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Re^isteved JVo,
\ Of ).3
Deputy Health Officer
DEPARTflENT tfF PUBLIC HEALTH-City and County of San Francisco
Certificate of Bcatb
( "U. S. StanDar^ )
^ ^ J?
No.
-y (fl?) J? (^
PLACE OF DEATHr-County^ofClo/.^ Jyv^x,:^e,Gty oiOo^ Jx<^v<^v^cc
X ox <tu (h C^^ WtlcLA > Dist ♦ bet J
/ IF DEATH OCCURS AvtAY FROM li S U A L R F qW" fU r r " "^^S^** ^ I* ^ and
I
FULL NAME U
Xi^v.
dc
vj
s !â– : \
DVV]-. Ml- l;ik in
\<". j;
PERSONAL AND STATISTICAL PARTICULARS
i"'»i,<)k
M.Mlth
rill
MEDICAL CERTIFICATE OF DEATH
DA IK oi- I)i;.\TH
Ii:. \-
Vtar)
I m-RI-HV ClvRTlFV. That I atten.lcl dcccascMl frn„,
190 to ■— —
aa
\\n»< m HI) Ok i)iv( >kii:i)
' ^^ ' " ""ial il< siiMiat ii >n)
MiK rni'i. ACH
' Slate or (• lint r\-
i
I
tlial r last saw li r alive 011
r-r:iQO -
~ 190 —
â– ni'l that .Icath occurre.l, on the <latr ^tate.l ahcvc, at
~ r^'' 'T7"^"n^ '>'^ATI^vasa. foll.nvs
â– 6.
NAM J- <»!
lA THlk
inKTiri'J.ACK
<»l lATHHK
'Statr or t'ouiitrv
''IMIM.V NAM)
<•! M'>rin-,k
li'k riiiM.ACi':
<M- MorilKK
''^l;itr i.r C.Minti \
A\A^'<}
'AAXiX/ayv JV<r^
?!
ITkA'llON
CONTkllU'TOkV
}'c'<7rs M,))iths
Pars
Iloins
I )I RAT ION
)'('ai-s
.'^finillis
Pays
' " *â– ' I'Vl'ION
'jmiL,
ICML IN FOR I
Hours
(SIGNED) LcY^^X/vO.^AL.oUi^,.vv<JL M.D.
SPE
v-v-tX
^
)V,n
^ 1/,.-,,'//- - /;,,
'InfuMnrml
I
yi^KN<.\\l,i.;i)C.H AM) Itl-l.IlvF
yv. 'I'l » riij-
When Has disea'.e ronfrarted,
If not ill plat e of deatli ?
I'l.ACI': OI' IMkl AI, (»R k l.M()\- \l
I N i)i-: R r A k 1 : k UCvou^ H- • vfc. \)|UJL'
l>ATlj..f iii KiAi. ,,i K>:M()\-Ai,
!N. "— ^;V';''y 'tern on„fon,„„tlon nhoul.! I,. c.rcV'uIly supplied. M\V. s,,„.,|<| ,
«tnK CAUSr or DI.ATH in plain tc
.e state.l fiXACTLY. PHYSICIANS shoiiM
-on. .„i„, ,.„„; ;;■,„ ■::: r:,.;;:";;;.";-;:*,::;:: ;:;r::r" ^'"""''"'- "^"^ ■'*'-'■" '"" -"•• '»
r p»*r-
^1
«i
t
1 1
s
1
^!f
•i
h
! I
[•♦i
i
'
II
1 j 11^
i»
' .
^-
H"^'
f
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
!l..:n.I ..f FI. ilili l- v.. I-, f-^^^W^) HSc\' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dff/r I'ihd, \Juu<x>^y^AXj \\ 100^
liei^isfei'ed JVo,
I ncvi
\A
Deputy Health Officer
DEPARTMENT OPPUBLIC HEALTH-Cify and County of San Francisco
Certificate of IDeatb
( H. 5. 5tan^arD )
PLACE OF DEATH: — County of C'/(X^\; 0/UX/'>VCAAC€City of C) CUVi/ 0XXL/Y\'C,v^/C<3
No.
•'CX^CL-r^ ^JXCV.ti.K'
St.;
Dist.; bet.
and
/ IF DEATH OCCURS AWAY TROM USUAL R E S I D E N C E G 1 V E FACTS CALLED FOR UNDER 'SPECIAL INFORMATION- \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF ST RE eI A NO N UMBER )
FULL NAME
<X/vuJUj
"-i: \
i> \ 1 1-: oi- i;ii< rii
\<'. !â– :
PERSONAL AND STATISTICAL PARTICULARS
COI.ok
Q?
'yVvCtx
JWL<UyvX/>v
Jx\r
MoiiDi
3
,V^
I go \
(Year)
3
t
0 i;.
ni;h s
\x
\ car)
/),
^IN'.I.i:. MARK II- I).
\\n)t>\v}:i) Ok DivoKn-T)
U'ritc in «)ri;il .!< -iLMiat i.>n>
iiiK rui'i. \rK
(Stiitt.- or Couiiti V
^^-V'
MEDICAL CERTIFICATE OF DEATH
DATK oi- i)i:ath r\
LWOL 15
I ni:Ri:i'.V Ci;RTn-V. That I mUcikUmI .loroasd from
— — 190 to - iQo
that r hist saw h ' — • alive on : — \ ^^^
and that (Uatli orciiried. on the date stated above, at
M. The CAISK ()!• DICATH nas as follows.
N.v.Mi-: III
i-Aiii i;r
IMkTlII'l.Af}-
'>!• lATIII-.R
'St;it< 01 Ciinti v1
MAlI)i:\ NAM}-
oi- MoTin-;k
I'-IK I'HlM.An--
OI" MOTH I -.R
'Stair I.I- <.-oiint!\ I
C' vu< cL-. ^ -.j
X 'VA.cr^^'
«•
M
IMRATION Years Mouths
CONTKIIirTORV
>"*-0-^-\Ji V'OL<a^ c . . Lv<r>>-^,
A-XXv^v Jt>vtjl>wvva
Pay
'S
J lours
DC RATION
)'(ars
.^fi^uths
(SIGNED) WumJiX; J.lc.Uj.XliLou
Pars
n rqoH
Ad.lle^s) \js\.-
Flours
M.D.
^\JJA^
"' cri'A riuN
-<Jl^
V.'.v//,..
/',;i .
or Recent Residents, and persons dyintj away from home.
Former or ^ Py^ J How long at
"'nrJTy.l^';^ •'"'■'* I'KK^ONM. I'ARTUTI.ARS ARl- TRIK T. . TIIK
H h ^ r 0 1- M N K \ ( ) \v\ 1 ■: I X ; }•: A N ! ) in-: 1. 1 h k
p^" ' '^ ^' '*» i, 1-. IM .1-, .\ N 1) JUM.IJ
I'sual Residence
When was disease contracted,
If not at place of deatit ?
-A^ ""« ionq at
.Ou(Mr>v or Place of Death ?
Days
190H
(\<\A
io»;,s
5-61
tPOAJLh^
3t
f Ad(hcss ^ H XH O <rCcLil/W "
V^
-'V^..,
^' "* TtaYe^'c i'l^virUr nTr^M" "''?'*' ''" --«''«f"">' supplied. AGK should be stntccf RXACTLY. PHYSICIANS should
!o^^l • . 01 DEATH 1,1 ph.m terms, thnt it may he properly claHsified. The "Special InformHtion" for per-
sons tlyinft «wny from home should be ftlven in every iiistnnce.
!l
it
i vl
i I
f.^
<^i
â– -^-^ f
-■% « *
â– y !V -'i^:i!>^'
r,
I .
#;
li
lal
^-«ji
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
)!m;,1.1 ..f lh:illll I- V<>. I^ *'-'_'5;^'i- I!S:l' ('..
Xtn^cv^i dOL^xhu Deputy Health Officer
JivgLstcred J\^o,
1 065
DEPARTMENT OT PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( tl. S. StaiiDnrO )
QK)
PLACE OF DEATH: — County of 0/<X-y^ 0/)^O^%OL^ecCity ofO/CLA^ 0 AXV^-VCaAXI^
No, 11013, X'xdvt^vt St.; ^5. Dist.;bet.C)ae>vayYvvt>xto and VAXXU.
/ IF DEATH (|)CCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER ■'SPECIAL I N FO R M ATI O N • ' \ -1
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / J
FULL NAME ^^JU.
o-ooo
^AA.
'i:\
1 ' \ I 1-, < .1- !;1K 111
Af.K
PERSONAL AND STATISTICAL PARTICULARS
COI.OR
^yUjUUr^^
H
(I):iy
i •: i
MEDICAL CERTIFICATE OF DEATH
DATH ol- DHATH
' ' It
(Day)
Moiitli)
TQO \
(Year)
an
) -
H
M.'iilh \
\ t ail
/',;
-iNi.i.j". MAkun-.i).
\VII)t»\VKI) OK I)!\-()k( I- •)
' \V: it- ill - • ■. --i^Ml;il;..ii)
lilKTHlM.ArK
(State or Conntrv!
O^A^a/Lo
I [ll':Ri-;nV Ci:kTIFV, That I atU-n.kMl deceased fn.m
~ '9° tn TOO
tliat I last saw h alive on
and that death occurred, on tlie dale state<l ahove, at -
â– " j^' M. The CAISI-: OF DI'ATII was as follows:
1 \ rm-:K
r-ikTinM,\«K
"I" I AlUHK
(Stat( or Ciiunlrvt
oi- M«)j-in;K
<>^â– MoTm-.K
I'Voa^O^
djLX.
.\^A^.<rwQ
nr RATION Years
CONTRHd'TORV
Mouths
Pays
II am
MJlXj
DIRATION
'W
)\ars
Monl/is
(SIG
NED ) JAJxIx>vaxJi 0. Cou-
Days
,
Rrsi,
s!ifr,f ni S,i)i /'i (! II, f^.'it ^\
-VOj
\ lie i()oM (Ad.lre-><) icO^ C
Special Information only for Hospitals, institutions, Transients,
lAC^^/q, lie i,)oM (Addre^<) (cO^ 3-'«-vttjl'X) Cjt
or Recent Residents, and persons dvjng away from home.
r.
1 A /•'//.
/',/! -
Tin: AHovi-. sTA ri;]) pkr^on-ai, p xKTicri. \k>-. aki' vkvk 'j-o rin;
l.J-.sr (>]■• MV KN-<)\Vl,i:i)C,H AM) lil'Ml.l'
Former or
Usual Residence
When was disease rontracted,
If not af place of death ?
How long at
Place of Death ?
Days
fiiif
o; iii:i!i
\<l.Irr>;^
I'LACl-: t)l* lURIAI, OR ri:m(.\-ai.
DATKuf" IM HiAl. or KKMOVAI,
(Ad
t
-5
■^' fivery item o»i iriformjition shoultl bs cnrefuily supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSr OF DEATH in plain terms, that it may be properly classified. The "Special InforniHtion" V'or pur-
sons dyinft away from home should be 6'ven in every instance.
^'^
' ''J
I
â– Is 1
ii
!,»
ll
ti
m
i
1 1
' c
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
!l.,:ir.l nf IlinUli I'" No. i >; <?"r=r; •»;-*■; |u«tl' Co
REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
JiegLs/e/rd A^o,
lono
d^jyu^^^ji doL/v-u Deputy Heafth Officer
DEPARTMENT OF PUBLIC llEALTH=Cify and County of San Francisco
Certificate of Seatb
X\. S. StnuDarD )
-? ^
^ Qm
PLACE OF DEATH: — County ofOcLA^^ J Axv>a^^:.^^<1/Cc City ofOcLA^ oAxx.
a
>VC^V<t''C^O
X^-XJ
No. 10 II MfU-vA.Ax<x. St.; .^ Dist.;bet. I 1 X^^ and li
r IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
\J
FULL NAME
-^lA
IiAll-: ol- I'.IKIII
\«'. !•;
PERSONAL AND STATISTICAL PARTICULARS
I Coi.ok
a,
iM.itith) A
);■„>
(I):iv)
M.nilh'
\^y\
cLu/^v-'
\\,K
(Vrar)
I hi
MEDICAL CERTIFICATE OF DEATH
DATK <)I- DliATH
,1
(I)av)
CL
(Moiitli) A
T9o\
(Year)
\VFI)n\VI-:i) OK ni\<»Rii.;i)
\\iit> ill social (l<si>.Miali(>ii )
IllKTHl'I. \ri-:
^t.i'i 1,1 I'oimti V
NAM!' (»|'
••Allll.k
lUk IMI'l. \< 1-
*»i- iAini:K
'State (.1 Ciiuntl V
"^1 Mlii;\ N AMI-
Ml M()rin.;u
lukriiiM.An':
()i- M()Tni.;k
(State or Count! V
T90
1 IIf:KI<;i5V CivRTIFV, That I Mllcii<k'd deceased from
'^^'-^-^ l^ up'i to Clvupi ll TC)oH
tliat I last saw h â– ' alive on
;i!i(l that death occurred, on the dati- stated ahove, at
'^ >r. The CAISK Oj- 1)!-:aT11 was as follows
'>II^\TI()N Years A/on //is /)ays
Hours
V'^w^-\..*.^:;>.-vw
)'cars
MoHt/is
C.C.^xm'..,.
/^a vs
<K"crrAii()x
AV' ,',//â– </ /// S,;ti f'l ,: 11,
a
0^'>v<\.
diratiox
(Signed )
iXwQ il i()oH (Address) 1 6 I U ^xv M Um- LLkc
Hours
M.D.
Special Information only lor Hospitals, institutions, Transients
or Recent Reslilenfs, dnd persons dyinu awdy froni home.
}V„'/ <
1 A â– /////-
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
flow long at
Place of Death? Oays
"",;.V!V^''"* ^â– '"'^â– 'â– i--i> ''nksoNvi, i'\k rhTF, \Rs \\<v. rkii' To 'i-ni-
lii-.si Ol.- MY KNo\vi,i:i)c,i.: AM) in: 1,1 1'.!'
' Iiiriiiiiiaiit
Wny>^ (/b. dLu/-.A^
< \.l.ln-.v ( 0 I i
Q.
I'l.ACK OI" lUklALOk ki:Mo\AI
IMJl'.kTAKllk
^\d<li
DA li;,i.f Him XI, ,,, ki:Mo\Ai^
â– '^' Kvepy item of Informiition shouhl be CiircV'iilly siipplietl. \V,\', should be stiiteil F.VACTLY. PHYSrCIAINS Khoulti
state CAUSE Of- DEATH in phiin terms, tl.nt it msiy be properly cluHfiiV'ied. The "Speciiil Informntion'' for p«r-
nons dyini^ nwny from home should be jiiven in every instance.
t .
'^^
m
1 1 ri
t<
«ip^
It"
I
/
t â–
I
•*■'■''■!
::^i
\ •
i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
i;,„,i,l ,.f !li :ilHi \ \'<
^<» ••*«*,
i- nf^\' c.)
I)
((fc Fih'f/, LA.aa.1
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
1%
HJO'i
ifruvv^. A-e.vvi. Deputy Health Offif^-r
l{rgi.stcrc<1 J^'o.
i Of)?
DEPARTMENT OF PUBLIC HEALTH==City and County of San Francisco
Ccvtificatc of IDcatb
PLACE OF DEATH: — County of^'cL/^v vl\<x>v c< <i q< City of Cl<X>\' 0A.O^>veA^cc
N(
o. 5 VJ)lA/>v<V^.cl'
(Jil
St.; 1 Dist.;bet. Oacc^C5\' and VO>\Jl>
/ ir DEATH OCCURS AWAY FROM USUAL R E S I D E N C E & I V F FACTS C A H F D FOR U 4d F R "SPECIAL INFORMATION \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTFA^ OF STREFT AND N U M B E f| /
FULL NAME
IVL
xxkkju 'h. Va/>\, Mil.
<X\.\-
si;\
\-
' \ 1 1 < i| i;i K III
\ « . V.
PERSONAL AND STATISTICAL PARTICULARS
\t-nth> k
n
t
r
'â– >S i^ >\< >\,^/'w^
MEDICAL CERTIFICATE OF DEATH
i» \ 11-. < II- i>i; \ in /^
f Month) ,V (Pay)
I III.1':I.I:N I I.K'ni-\-. 'IMiat I Mttciiik-.l .Icrrasr.l fi.-iii
t li.il I l.isf saw li ' ' ali\i' on
(V.'.-it)
U)0\
i\>.i,i:. M\Kkii:n
Wi
[!• ; a -. )i-i
liiK I iii'i.Arj-:
'Siiilf or Co'nili V
lA in i;k
i'.!Ki"ni'i,\(i-;
'"' I'xrnr.K
'>t,i|. 1,1 ('(iiintrvl
MAIIU-.N NAM}-;
«»)• Morn I-; K
iiiki ni'LAr}.;
<>1' MOTHI'.R
' ' ir A 1 ION
Kf'-iilci III Snii I
I
Cl'^x,
ami lliat <1< illi occiincil, nil llir .lalt^fafnl ahovc at U '.^0
M. llH' <^^\|■Sl•: Ol- |)i;.\TII wa^ as follows:
Q^
0 AyO.
CoNTKIiU'iOKV
Mouths
> >> s
/^'/rv v> l-fours
/t)
DiR \ri( )\
)j'(;/.c Mouths
(SlG
NED) ^IH. lb. Lt/tivi
/hws
lion
Is
t/vM.X\
.\^<X >V^«L
Lltcq n i<pH (A.i.irrss) H(>li.> )Ai.ll>:.s. ' Vi
,<\ It T<)f
dllAL IN
1
M.D.
SPEd^AL INFORIVJATION "'I'v (or M(is|ii(,iK. Inslilnlinns, rninsienls,
or Recent Rcsidrnts, and prrsoiis d\iiii| ,iw,i\ linm homr.
M..,,il,s
lK-\'
fornipr or
Usiidl Residence
When was disease ronfrarled,
If nof at pjai e of death ?
How lon(| at
flaie ol Death.'
Days
I 11 1 \ HoVl.; s r \|-);i) IM-' kso\ \ I. }• \ R r |t I ! Nf- \!'! ri<' I- To Till'
lll'.^T Ol- MS KN(t\VM-;i)<,|.: \\l. It, 1,1! I
InfMMiKiiit
.^LO<y>r^
^-
I'l, ACI-; ()!â– r.iKiAr, ok r i,\T( >\ \ i,
i
II, \l I', I >!â– lil K
Wv
IQOS
! N I » 1 : R T A K i-: R
^\(!.lt. -s
I> \ ri: m! Hi i-i \i ,,i R i;M( )\- \[,
r
•^* ^- Hvery item o»* inH'oi'nmt inn Hhoiihl be cnret'iilly Riippriecl. AGP; sho-.ild be stntcil l.\ AC TI.Y. PHYSICIANS Rhoiild
Htiitc CMISr or ni.ATM in |>lnin terms, that It mjiy be properly clnHHili'ietl. The "Speclnl Inltornmtion'" Inr par-
sons (Ijin^ iivvny I'roin home sliould be 6'^^" '" every instance.
fi
I'
» \
I
» >i
'r.\
» .
i
««n|M
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
»>r
)l,,:iT.l ..f nr;i;t1i !â– â– V" '- t-.-ix_^>i: Itftl" (V
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
\/)afr F//('f/, LU^qu^vCt \% /^V^^H
llcgLslcred JS'^o,
ior>8
Deputy Health Oflflcf r
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Sheath
( n. S, 5tnn^arc> )
S! (^ J?
(^
PLACE OF DEATH: — County ovJfXrr^ J/ucx. \^-ev-(^c(. City of CJ/tX/>v. J /v_<x/N^tv<i,-ac
No. 5 'vh
.'iXAw'^vOu'vcC'
St.;
\
Dist.;bet. Jo^v^Cr\.
and W^AJl^'5
(ir Dr«TH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR U nA) E R "SPECIAL INFORMATiAn' \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAli]oF STREET AND N U M B E W. )
/-Of ^
)
FULL NAME LK JLd c [. M WoJx^^Jb^^ V<Xo^
si;x
1» \ . 1. < I! 1; I kill
\' .1-;
PERSONAL AND STATISTICAL PARTICULARS
ft t^oiok
â– ^xX'^
ll.
i^^^\^L
h
^
I —
MEDICAL CERTIFICATE OF DEATH
DATl-: ()!• Dl.AlU
\Xj^\
MMiilhl K
v,,/. l^./nH
) ^i**.^ .
: i.i: MAkk n;i)
WIImWHI) OK I)IV()K>):i)
^' • ■'■ill voci.'i' \ -'-n.il I'.ii I
Iilk IHJM.ACK
'State or Coimtrv^
1 Alllllk
lUkriii'i.ArK
'>i- i-\rin-;k
"lit' 'If C'i.UIltl\-
MAinMX NAMl-
<'!• M()THl-;k
liik riirLAci-:
OF MoTinCk
'Stat'- or Tduntrv
ir Alli IN
iH
^MoiUli) ,J ^Day) (War)
1 III-;RI-:RV CI;RT1I-V, Thai I attcinUd .UvcascMl fn.m
LLc^o n lonH to . LLlvcl n too
UwA^^ 1 . up
and that lUalh orrurrcd, on the (hiU- stated alxiVL- at l^
^i M. The C.\rSl<: C)I«' I)i:.\TII was as follows:
til at I hist saw h -^ '>x alive on
DIRATK^N ]'cars
CONTRIIUTORV
Moulhs /)a\s \X//ours
/\.0 ^ â– C<L
I ) r !>: .\ T I < ) .\ ) V.7 rs JA V////.V /)avs I 'J. Hours
(SIGNED) \l/\ \ CtcJ'VtM-«>uHAj M.D.
LL^v^a ri T(,o'i (Adduss) HOb Cj-v»JXt>v> ^:i
a
)t
SPEciAL Information only for Hospifdis, institutions, Transients,
or ReienI Residents, .ind persons (l)iny away from fiome.
/
in; \v )\'}-: si' \ I) II )'i-- kx )\ \i. i' \kihm- i. \ks ak i-; tr vv. to rii v.
lii'.sp oi- >i\- K N. iw ij;iM , 1-. \M> i!i:i,ii;i-'
Former or
Usual Residence
When Has disease contracted.
If not at place of deattj ?
liow long at
Place of Deatli ?
. Days
ri.ACi; ()!•' lukiAi, ok ki;mo\\i.
DATi:..'" Hi iMAl, or ki;M(»\-Al,
) y
IQOH
N I ) 1 : k !• A K V. k >V,*JLa^ V>? *^ ^- O'tLc
CLA.\J
(Address 3)0 5" VnXfr^-vtcyA.. LIa>jL .
N. B. livery item olt i n form :it ion should be cnreitiilly .supplied. AGB .should be stated HXACTLY. PHYSICIANS should
Htntc CAllSf; OP DEATH in pljiin terms, thnt it mj>y lie properly classified. The "Specinl Information" for per-
sons dyin^ away Prom home should be given in every instance.
â– â– \\
•I
^
* I
I -d
^
' d
» 1
1
T
II
I
It
L,
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I!. .;il.
Ilr.iUh I- Vo I- â– ?
f^r^'\-
USi. V Vn
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
lir^istered J\^o,
10G9
Date Filed. CLa^o^vxiI) \\ 10(n
^rvc^^ XiLxv^ Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
f 11. 5. Stan Da rO )
of ^ ^ ^
PLACE OF DEATH: — County of^/CLA\^ 0 ^UX/T\.c>ui.cc City of vJcl/>v OAXX/yve^^XL^o
No.
J?
f IF DtATH OCCURS AWAY TROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION"
vv.<: CjKX'VcaJUA.c^St^^x.- Dist.;bet
land
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE rTS NAME INSTEAD OF STREET AND NUfMIBER.
FULL NAME
)
PERSONAL AND STATISTICAL PARTICULARS
•-l-X (^ A j COI.ok
i'\ n; ( n iwK rn -^ a
M
.1 A. >/,'//
%
I Ti-iir)
/',/!>
MEDICAL CERTIFICATE OF DEATH
DATH K)\- l)i;.\TH
(Month)
a)ay) (Year)
^i\' i.i; M\ki<n-:i).
\\ii»< )\vi-:i) OK in\()K('i:n
' Wi iti in -ix-inl •!» s-'v it;it i'Mi )
HIR rill'l. \kM':
'Stati or i.'i iiintr\'
ia'ih):r
lUR rniM,ACK
' state oi OomitT vt
MMDI'.N NAMl-
OI MoTlHiK
I'.IKIHl'I. Acr:
OI' M«trin-;R
fStat'- oi Cuiintrvl
oiATl'A'i'n )N
I HI'RiaJV CIvRTlFV, That I attcii.lcl .Icccased from
Laaa^o 190 1 " to LU-<v/Q^.n up \
tliat I last saw li -^^^ alive on LXa.a.x^ '"1 i^o M
aii.l that (Katli occurred, on the date stated a])ove, at I 3..0
V M. The CAlSiv ()!â– l)i:.\TH was as follows:
^
'S\
XA
'^'^WLry>,AJ\A>^iA.AryK
0^'W<i.
Rfsidrd in Sav i'lan. i 'â– ,> \o ! - .m v
DIRAI'lON ]'i'ars Moujh!; Pays //ours
CONTkllU'TORV 9.<^>-oJLc
at ()ox<x^t
DIRA'I'IOX )\'ars .}roNt/i.s Pays Hours
(Signed ) vjX^)\jI/^^./qx Ml. \X'<x>v^ MD
J? â– '
\\ rqoH (Ad.lrc-^s) toOb QJA^fctx\. 6t)
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dyiny away from home.
Former or ^-,
I'sual Residence ->0b
M,.>,th<
na\:-
'\'\\v. \U()\-i.: s'l" \ri'. I) i'i<:ks( »\.\i. r \rii rr lars a r i'. I'Kri-; r( » rii v.
nKST OI- MV KNo\\I,i:i)C, H AM) I'.l , 1, 1 1! 1-
'i'>ro;,„,u,t VlfUvo 0. vi\ Qi\jUx^<:^a.-y.,.
Uddnss 3>C) b
0^^<X..\^\J\JlXj
jLl. How long at
CTL Place ol Death? I 'Y^ -ftjys
; disease contracted, 'I i 0
place of death ? \XJy\M/w^b^^''y>o
ri,AC};oi' lURiAi, OR ri-;mo\ai.
(jIdCtIu Vv'fe-^^
rNDl'KlAKKK
I)\'n-;o!' I'.nuAi. or Ki:.Mo\AI,
(Address
Tt~i M)Vva^v(„tr-i-o ai
^- '*• Kvery ittm olt information should bj .iircfully supplied. Ad'B should be stated F'.XAC TLY. PHYSICIAINS should
state CAUSE OF DliATH in plain terms, that it mny l>e properly clussiltMed. The "Special Information" for per-
sons dyin^ away from home should be 4iven in every instance.
i
I •
i:^
I,.;
â– s
h\ A
Id
I
(1
f
t !
fl
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
!:- .:!!
1 ,,f Ilc.ilth 1" No. It.
•t^'-ar^; iiS:!' C
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/)((/(' Filed ,
i
\%
IfJO'i
BegLsfet'od Xo,
^ OTO
Deputy Health OffT-f^r
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of Beatb
( 11. 5. Stnn^ar^ )
PLACE OF DEATH: — County ofOCL^O; vLn^/O/TV/e^ULCCCity ofO.<X/vu 0 AxX/W'Ouiyeo
Ox/xti'
No. 5 0b Ox/xUt^' St.; H Dist.; bet. MU ^J^vOla^ and VyUKXXAWUXm.' )
(IF DEATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR U rA> E R "SPECIAL I N FO R M ATI O N ■• N
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAbJ OF STREET AND NUMBER. /
FULL NAME U^JL^cl^- Wvv^^JuxaaXkx;
PERSONAL AND STATISTICAL PARTICULARS
si:\
UcJlx
i"< »i,i)k
kllxjt.
i
^
• 'I lilKTIl
\JJ^K
Moiithi h
lb
\'.i-:
t V< .11 »
0
M \K \< ii: i>
\\ ID! )\\ 1,1) (»U lil\( (R'KI)
iWiitfiii 'â– iM-i.il (It -i^MiMlioii )
Ml Ml â– \
NAMI- (H
!• ATII J- R
I!IKIII1M,.\>1-;
<)i' i-\tiii:k
"^!:it'- .11- roimtivl
<»i M(»thi:k
liiu riii'i.An.:
(Stiiti' or i'(»iiiili \ I
" - 1 I'A rioN
J? ^ (J
\ \\
MEDICAL CERTIFICATE OF DEATH
DATi-: oi- i)i;ath r\
(Muiitli) K (Day) (Yt-ar)
I 1II;RI;I{V CI;RTII-V, Tli;it I altended deceased from
^ (1
lli;it I last saw li l .. alive dm LA.Aa,<V 15^
and thai dealli occurred, on the <late stated above, at V.'
M. The CAISI'; OI- DIIATIF was as folic nvs :
Tcpi
DIRA'IION
)'fV7/-.V
Mouths
/hivs
Jlon
rs
(ONTRIin'TOkV
1)1" RATION
^Signed )
)\-(fr.<;
JA '////' s-
d . Uj . 0 cy^KLoJLxj
I^ays
/fours
M.D.
iXcCQ IS rpo'l ( A dd r. 'ss ) '^O'S UjAvcv/O^vxt ;.Vi
SPECIAL INFORMATION "nH l')r Hospifdis, rnsfitutions, Irdnsienls,
or Retrnl Residents, and persons dyinrj dway from home.
rJIl' AUOVK STAI'l" I) I'I'KSox \l, I'\K 1*1(11. \k-> \K 1
HK.ST <il" MY K\< »\\ !,I l)i,i; \M) HI';!,:)
K II-: To vwv.
' Inf.,: iiiMiil
' Vl.lrc.v. 5" 0 b ^ Cs XJi\> ot
former or
UsudI Residence
When was disease rontrd( ted,
II not at plare of death ?
How jonq at
PIrii e of Oeatli ?
Days
I'LACi: <»!• HIRIAI, ok RI'.MkNM,
DAIVK'-: i;- II \i ,,i k ):.M< »\-..\i.
I90H
^'. B. Hvery item oil* Jnformj.tJon should »>e csirefully Kuppliecl. ACIK should be stated LX4CTLY. PHYSICIANS Hhoiild
state CAllSr or DI;ATH \n pljiin teritiH, thnt it muy be properly clusMified. The *'Specittl Inforniution" for p«r-
R^n* d>m(> fiwny from home should be iltiven in every inHtnnce.
4
'*.i
P'
' J
â– I;
' i!
I!'
»ymm
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
P
'f
i
);. .;l!'
,f II. :illll - 1' V(
f^m ''''•'"'^.
â– art.y^i- ]>f;^i> c<>
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I)a/r riJrd, [Xa^<yj<J^ \\ 290\
Jfrd/.sfrred A^o.
1 0? 1
u Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificate af 2)catb
( XX. S. StanC>arC> )
PLACE OF DEATH: — County of U /CUcn^x^-v^OcJ^^AXi) City of ^ <XAi/\^<:x./-yy^JUy-dio
No. LCrVAy>\Lu, (J^>Ci-<U^xLcu.
^ 1
St.;
Dist.; bet.
and
/ IF OrATH OCCURS AW*Y FROM USUAL RESIDENCE give facts called for UNDER "special INFORMATION" \
V if DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
si:\
PERSONAL AND STATISTICAL PARTICULARS
i> \ii-; < ii I'.iK I'll
X.'^OxJL
MEDICAL CERTIFICATE OF DEATH
DA ri-: ()!• Dl'.ATH
Month) A
C
V.)
I I
I go
(Year)
NUknthi
XX
1
<I»:iv
Mn'llfl^
;n )
n,!\^
^i"-«.i,r M\ki<ii;i)
u iix »\\ HI) i>K i»i\'<>Kri:n
' Wt iff ill wi„ i-,1 ,1, ^!;Mi;iti<iIl)
I!IR lllll. \r\-\
(St.M' • ' ■iiinli V
Ia^vaAj^
nKiiii'i, \c}-; X
>i- M<»Tm-:K I)
'Moiittil A (Day*
1 III'RI-r.V CI:RTII«'V, That I atU-ii.lr.l (ItTLascd from
to
1 90
lliat I last saw Ii ^"^ alive on
T()0
190
and that deatli oi^-urred, 011 the date stated ahove, at ""
•"- M. The CAlSlv ()!• Dl-iATIl was as follows:
•I if
V <X/yvdL
NAMl-: ()!
i"A riii:K
I'.IK rill'l, At M
<>1' lATin'K
•^t.iti- nr <'(iiinti V '
MAIDl.N NAM!
f>I- Morniik
1)1 RATION )<ars
CONTRIIU'TORV
A.-A^>VX
Moil //is
F^ays
/louts
DIRATIOX
)\i1)-S
Moiilhs
Days
^K >\^0.
' ii'AriMN S)
h'/'idfif ill Siiii /'i iiin I 'f'o OS c\ )'rii i ^
dL
M., lllll'
(Signed) mttl/yx; ck. UOJ^ujtt
n I 5 fo'T
LLv.V/Q lb T(,o H (Address) (j/O.OvXX/^'vJywto \_,ckX)
Hours
M.D.
SPECtJAL INFORMATION only lor Hospitals, Instilutions, Transients,
or Recent Residents, and persons dying .iway from fiome.
rill \i!o\i: s r \ ii- 1. pi- kson - -, r •, k ricn. \ks ari, ri< r i'. i' » 111 1
lil-.sToI MV KNdW I.I.DCK AM) l!KMi:i-
niif.i; ni-iiit
V KNdW I.I.DCK AM) IIKMi:!-
\.Mnss \ \\ \Jx>V/Qu\XX^ VA\>-L
Former or
I'sual Residence
Wfirn was disease contracted,
If not at place of death ?
Hdvv long at
Place of Death ?
. Days
HI-' lAi. Ok k i:m( i\a I,
i»Air,..; Ill KiAi. (,i i<r:M()\Ai,
190H
I M
) I •: K T A K i- kM I I 0 <xxiAx/vo \| iV mViLaviu ^ 0\Jli/>\'
i^' I*. livery item <>V* inVormiit ion Hhotild bj cJire»iiM.v siippliecl. A'JH kJv)iiI(I be ntnted HXACTLY. PHYSICIANS Hhoiild
state CAUSI: OP DIIATH in pljiin terms, that it miiy be prf>pcrly classified. The "Special Information" for per-
sons dyin^ away from home should be ftiven in every inHtnnce.
t
A' 1
I
m
^^,
»''i
«i(i
II
J
f
I
- - Id I m
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
r.oanlof Hfiilth I-' No. i>
,t?!^J!*v
i; nfkV ('
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dfffc I'^iJcd, LL<wA^Q,>uv.<£t 1*^
(X./()-AwA.-A^O
l!)0\
Deputy Health Officer
Beg i tit c red J\''o.
< ^72
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
4 %
PLACE OF DEATH: — County ofOo^/Vu 0 ^Oy^vo^Ci; City of O-CLArv OA.<X/^x^v.^i/c
ISk>, VwCtu,^L(rV^^Ajjj ^b CK^vCto..!' St.; Dist.;bet. and — —
I /if death 0CCU*S away FROJM USUAL R E S I D E N C E Gl VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION • \
\1 V If DEATH OCQURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
o
FULL NAME
X/'
o<yyT\j
]XXAJ\Jj
1 \
PERSONAL AND STATISTICAL PARTICULARS
, Col.oK
(W
i) \ ri". <)i' iMKrii
A <■.!•;
' MMiith)
IdO
)
I I);i\-
!/.,»////.
/\,\
^I\«", i,i: M\KI<Ii:i)
IfsifiKit ii III )
lUKTmM.AiM:
'Sl.'itf or Count I \
NAMl' til
lAllll.K
HIk THIM, At)-;
<n- lAini'.K
f Stiilf or l"ounti V
M \l!>i:\ N AMI-:
"; M'trin; K
lUKTHPI.ACl-:
<»!■^:l>'l•Ill■•,k
(St: < .niiitr\i
(Voar)
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH |
(Mouth) A (Day)
1 HI:RI-:15V CI'.RTIFY, Thai I :itten(lc<l (IcHvased from
Vl (Uxu l\ 190"^ to LA^aXL i1 I90 H
that 1 last saw h Ay > > \ ahvc oti vA^vvC^ I ' ^ j^o ' i
and that lUatli oicurrcd, on the (hitt.- statt-d ahovc, at Ci â– I 0
Uj M. Tlu' CArSij;^()I' DI-ATII was as follows
0 ^^^-A,V^.A„/C;A^O0t>-^sl.<^w>0.
1)1 RATION )'('ars
CONTRIIU'TORV
Moulin
Days
1)1 RATION
Years
(SIG
LL\xAi\jLLv%
Mouths
Days
LIa^Q ri i„nM (Xd.lr.'^O '^vtu/^ VJ). feo^
:iAL
Hours
Hours
M.D.
^
OCCl TAIION ^ . 1,
^ /
I' HI'. Miovi-: sTA'n-'.n im-'k^^onai, p akiuti.ar"-^ ari". IK I1-: !■•> Ill i:
l!i:sr Ol' MV KN't)\\Ij;nC. H and jniMlO-
Oufo-jnant VwaJ rwv.' . \/ /a
Special Information only for Hl^pitals, Insmutions, Transients,
or Recent Residents, and persons dyinij dwd> froui home.
?
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
HoM long at
Place of Death?
? "M
Days
I'LACl*. <»l" IM'KIALck KIMm\ \I, I ItAI'i;.!; lUmAi, oi Ri;M(»\\i
INDllRTAKKR ^^TL^CtX^ lLA^cLJt^X<xJkxV
(Address ob^ Vj lXAw/iLA.\.^Cr>V. O .t'
N. B. F.very Item of informntion should b. cirefiilly supplletl. A(iB should be stnted RX4CTLY. PHYSICIArSS should
«tnte cause: OP DIZATH in plain terms, that it may be properly classified. The "Special Information" for p«r-
«on8 dyin^ away from home shouM be Jii>en in every instnnce.
\-V:
I i
A I
' «i
I'f'l
i
i:
' i
'-^m
J
Hi
I
â– M
WRITE PLAINLY WITH UNFADING INK
***'*'"»»
.1" llinU
h 1" N'" :■■■?'-^, .'».■-:-» li'^l' *
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I)((/r Fi/r(/, CL.v.<Y./^t \% I'^OH
Ko^istcred J\^o,
1 07.3
^^ Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Cevtificate of IDcath
( 11. 5. Stnnc>ar^ )
•^ Oil) ^ -Y ^Uli
PLACE OF DEATH; — County ofOoi/Vu 0 AXu^X^^ULCCCity of Ool/Vu J AXXy^VC^ULC^
-9 ^
No.
I
<X\^< Vi<X
AA-Cr>\^ (jbchAl/K^-t'oX St.;
Dist.; bet.
and
/TiF DEATH OCCURS AWAY FRoWl USUAL B E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
\\\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
^!.\
PF.RSONAL AND STATISTICAL PARTICULARS
" \i\Li^
I • '1 IMK 111
vA,/"v>^r
â– Month' iDavi
\<.K
b
)â– -
1/..I/'//-
t \ i;ir
/^<M,
•^INi.l.l-" MAKKIl-.n
wMx i\\i:i» I >K Divi tKri-:n
I'.lKTHI'I.VOl'
' Stilt'- or I "< â– lint ! \
N \M1- ( 11
i-.\tiii;k
lUUTHIM.AfK
(H I xrnHK
< St;itf or Coiinti \'
M\!I)I:N' NAM1-:
-'' MoTlIl-.K
Hiu rniM.Aci".
(Slittf oi v"oiint t \)
J ^ ft
.\,m£L
c\;
190 'i
(Year)
MEDICAL CERTIFICATE OF DEATH
DATi-: oi" i)i;atii ,^
iMoiitlO 1 (Day)
0 -
1 Ili;Ri;nV CI;RTIFV, That I attended deceased from
i^JO 10 icjoM to LU./c<1_. 11 T90H
tlia't I last saw h rV\j alive on LAa.^vo • \ icp 'l
and that death occurred, on the date stated above, at \
Ob M. The CVrSl- OI'" Dl'.XTIl was as follows:
0 ,.O^JU-O\/^l>oJ<L-0-<k^*^^ Crir o^-Vwr-vr^X
>^
I ) r R A T 1 0 N ) 'I'ars C> .}/o)il/is /hi ys
CONTRIIU'TORV dJ ^^â– OJf\.KA\^â– â– ^<:^.J
J/OIDS
J? ^y J
O^A^ 0 AXX^'V ^lyLA.'CC
' ' I I'ATinx
1 ,
\r,nitll^
/>.;^
I'm-: Alio VI-: st xd-: i> i-kk-onai, pxk rnri.ARs aki-: rKti". k • i'
H1-:ST OI' MY KNoWI,i:i)(",l«; AM) Ml-J.Il'.K
Infi-ni.itit
vJ^yO^vCU) ^
(A«l.lu-
CtX) ^ A-^-^A.^'v
..aJl
H— -4
I lours
M.D.
I) r R .\ T I ( ) X ) '< '<? r^v \ Moil t/is /Mys
rsiGNED) ^^. Js ()ocru>cuv^
lX<.A^ ("L looS (Address) 3Hl ^,0^^1jI^' 5)1
SPEciiAL Information only tor Hospitals, Institutions, Trdnsients,
or Rerenf Residents, and persons dying away from tiome.
Former or k
Usual Residence
Wlien was disease contracted.
If not at place of deatfi ?
flow lonq at
Place of Deatfi ?
Days
I'l.Aci-: OI- r.iRiAi, OK ki-:mo\ai.
I)\rK.)t iiiKiAi. or R1-;M()\A1,
\Xj<J^yO, \^\
i9o'\
N.
R._nvery item of Information «houUI b. cnret'ully supplied. AGF. should he stated CXACTLY PHYSICIANS should
Htntc CAIISF: OP DIIATH in plain terms, that it may he properly classified. The Special Inlormat.on kor per-
son* dyinfi away from home should be g,\yen in every instance.
' li
*
i
1:
if:
11^
* ' â–
i'SB^P'
I
f
(,
•i'f
i
^ iliii
WR
ITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
illh )â– â– N". I
•'"Z^ .
." '"• ''3f'.
Wis. 1' <•
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
li)()'[
IlciHislriuul J\^().
1074
hale hllcd y LL^-a^qa^^a^Ij" \\
â– Wc^o cL^u^ DeDutv Health Offi,.^.
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate ot 5)eatb
( XI. 5. t5tnnc>arC> )
J? (to A ^
PLACE OF DEATH: — County ofCjCt/Yu 'J.\.<X/^a.,C^<i cc City of OcUYo OAXV>vcuiyC^
i
XX-'>'v<xl,c\.c«>-c'A>v' St.;
Dist.; bet.
and
H /OCCURS AWAY FROM USUAL R E S I D E N C E & I V E FACTS CALLED TOR UNDER "SPECIAL INFORMATION • \
"^ I INSTEAD OF STREET AND NUMBER. /
OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME
FULL NAME
• l.\
PERSONAL AND STATISTICAL PARTICULARS
t)
I
Kt^<Lt.4vAv'
hJLAX
>i i; I Kill
Month*
Ai .]•",
) r„
I l):i\-
M.nilh'
S
'»■« :il I
n !
s|\(,l.l-. M.\RUIi:i>
\\ ii)<>\vi:i) OK ii!\( >Rt" i:i)
•Wiit. ;n -ori.-il dcxi^'iiat i< >n )
lA^ ^ V
HIKTHPI.XOK
\ \MI- (»l-
I A III i:k
MIR rniM, \ri-;
oi- lAiin-.K
' Slate <ii Cntinli \
MAIDI'.N N \Mi:
"1 MoTlll'.K
iMK rni'i.At'K
"1 NtoTIIKR
' Stale (M r<i\ititi \
MEDICAL CERTIFICATE OF DEATH
DA Tl-; «>!• Dl.ATlI /O
(Mniilh' /T iDav^ (Year)
I III'IR I'.I'.N' CIvRTll'N', Thill I atti-inU.l dci ».;tsc»l Inmi
W^VCL \'i Iqo'1 to vXv./U3l. 1% IqoH
^ â– Q ^ ,^ 'i
tlint I last saw h '• '■alivcon VA-Va^ It k^ \
and that (kalh oct-iirrcil, on the date stated aliovi-, at ^5
^ M. '\'\\v CArSI-; Ol' DI'.A'ril was as follows:
I )r RAT ION
)'t'ars
M,>n//is
Days
CONTRl 151 TORY \J AjL^^^^v./CX.C\,^.A^ Vi)j.A-VAl.rvj
//our
nrRATION
h
)'iars
J -^CU â– j'V'CJL
< H'Cri'A'IKiN
h'r- :,lr! ill V,.-;/ /'/ ,,'/,',
)V,.M
- \[,,iti,< s
l>.:\
I" HI", AUo\•I^ Sr \l"i: I) I" KK SON A I. 1' A KTir I" I, \ K > A K I ' TRI 1" 'l'< » Til l'.
H1-;ST ()1 -^IV KNOW l,i:i)(,K AND IJllUIIil'
\.Mr.-^>^ 1 10,
VI Kxx-OLxm
(?1
<Xti,j£-'
^f,}lli/!:
Par
//ours
(SIGNED) "^Su^ (]lj. NIVwaJUL^ M.p.
CL^O i'^ T<,nH (Addn-ss) l^O' H (Po CKA^OA^O.t
cA,^C\, lb T<)OA (Addn-ss)
PEcmL Information »ni)
Special information »nly lor Hospitals, Institutions, Transients,
or Recent Residents, and persons dyinj away from home.
Former or ,(
Usual Residence l ^^
When was disease contracted.
If not at place of death ?
CVV \ (T)(] Howlonqat
.\J I UtxXXM VJ^ta <l.fL Place of Death ?
Days
i)\Ti:«i! HiioAi, <)i ri;m()Vai,
11^ VO^ IH 190H
rL\ri': or imriai. ok kisMoxa:,
I ni.i:rtaki:r >-^- 0 CK^LjUx^^^
N. B.— Every item of information should ho cn.cfu..y supplied. AGF. should he stnted J.X ACTLY . ^"/J^j;:;^'^,:!^^;;;;';*
state C AllSr OP DLATH in ph.ln terms, thnt it may he properly class.^.ed. The Special Informat.on for per-
son* dyini iiwny from home should he jiiven in every instance.
> • I
-f "
t .'•1
^1
n
\'\
>.JI
1;
%
\
JL,>^.
Iff
u
\U>i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
.,.,..,,i..lil. , No uiJ^^H&l'Co RCPER TO BACK OP CEWTIPICATC FOR INSTRUCTIONS
l)<(le Filed,
vx^ in 100\
Begistered J^o.
1075
, Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( "U. S. Stan^ar^ )
(^
PLACE OF DEATH: — County ofC'<x-iv O^Co~.xcv«ict City of C',CL/>v OAxx^/wcva^c^
r?».'
0 u C^V»y>axLLc^xQ Us-^-^^CVA-vv.Sfc; ------ Dist.; bet. =^ and
t ir DOTH OCCUKS .*«» f»OM bsUAL RESIDENCE OIVC r.CTS CALltD fO« UNOEO -SPtCI*!. 1 N »OI< M.TION " ^
(. ir Dt.TM OCCU.^" '» • "^•"'«'- O" mSTlTOTlON GIVE IT» NAME 1I..TE.0 OF STREET .1.D NUMBEH. J
FULL NAME
â– )
::>.\/
^'••" 'W
"J
PERSONAL AND STATISTICAL PARTICULARS
I COI.OR
DATK Ol" IMK TH
A • . H
y\xut^O
M< iith>
(Day)
I ■/•</;
sIN(,!,K, MARK IK I).
WIDnWKI) OR IHVOKiKl)
iWritiin scxMal (UsivMiatiou)
niRTHl'LAOK
'Statr or Conntrv)
NAMl". <)l-
I-ATIIF.R
HIRTHI'UACK
OK J-ATHKR
(State or Country*
MAIDKN NAMK
«)1- MOTHKR
HlRTIiri^ACK
<)J- MOTHKR
(State or Country
OCCUPATION
^
/^/>r^
M.iHlhs
1^,
â– â– ^ -- ' i
( Vt-ar)
Pa \s
C'/(X >v 0 Axx^o^Ok.>^eo
MEDICAL CERTIFICATE OF DEATH
DATE OK DKATH
(Month)
(Day)
IpO :
(Year)
I I]!':kI<:BY ClvRTIFY, That I attended deceased from
Au.. \'\ 190'i to LwoL i.i 190 H
tli^it I last saw h "SA; alive on lX^.<^-a. I "I 190 M
and that death occurred, on the date stated above, at 5
V M^ The CATSIi OF DIvATH was as follows
^ ..^ ^ 'A I'lv.Aii
V/O
DURATION }'ears
CONTRIBUTORY
Mouths
Da vs
Hours
wJAj^-K^^sx^j^yxj
)'i\ii f
M,»if/i^
/>,n.
imj: aiu)vkstati:i) phrsonai, kartutlars ark; trkk to thh
ijkst ok mv knowkkix.k and hkmkk
(Infonufint \l iV . Q \J y\oav>^iJU..O^U(j
Ov^OC) JxJul^X'trNJl.at
(\<l«lress
DURATION
) 'cars
Af()f///is /^ays
<xXJj.
A.\.q,. lb. iQo'-. (Address) ^^ ^ ^ ..^jJJuy\\A!\Jlj.\}i.
(SIGNED)
a
Hours
M.D.
SPECIAL Information only for Hospitals, Institutions, Transifnts,
or Recent Residents, and persons dying away from home.
Former or
Usual Residence
rthen was disease contracted,
If not at place of deatli?
How long at
Place of Death? Days
I'i,ACK OK BIRIAI, OR RKMOVAI.
UNDKRTAKKK J^JlXJLu ^*^ (JV) <XOy-a^^
:ss 'hS!>^.'X- I'^iJv \
DATK of HiKiAi. or REMOVAI,
IQOH
(Address
of Information .hould be .^rofully .upplicd. AGB should be Btated EXACTLY PHYSICIANS •hould
E OF DEATH In plain term., that it may be properly cla-ificd. The 'Speci.! Information" far rt-
N. B.— Every item
state CAU8
«on« dying away from home should be given in every instance.
%\
I. .>
1*
'I-
y\
A
â– 1 1!
( fl. â– â–
1..'
;i''
('
I, H f
i>\,
ti
I
MMjL
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I to; 111
1 ,,f M<!iltli F No
)&S3k) HS: r c
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dfffe riled, CLu^a^v^t l^ 100\
X^w^Jl^o^u Deputy Health OfHcer
Registered J^o. f026
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Death
( U. S. Stan^ar^ )
A '^
PLACE OF DEATH: — County of CVO-'>v OXOAx-CvAccCity of O CU>v 0 AXL/vxAiA,<i,ao
*
'No.
lu "^^ '^^^'^^i^H. 'Jl^O-<l
AvJ.
ri.
<xl St.
DisU bet. and
(IF DEATH 0<
IF DCikTH
CCUni *W*V FROM USUAL RESIDENCE give facts called for under "special INrORMATION" N
n . . __ ,..,.«», ,-.«r .TS NAME INSTEAD OF STREET AND NUMBER. /
OCCURRED IN A HOSPITAL OR INSTITUTION GIVE 11
)
FULL NAME
iUAUx/yxAj
si:\
I)\TK Ol- lUKl'M
AC.K
PERSONAL AND STATISTICAL PARTICULARS
I COl.OR
X)^VA.Xl<.
t Month)'
1^ ,..„,
(l)av)
M.inlfts
r V'\
(Vi-ai)
/></!.
^INt'.I.l". MAKKIi:i).
UII><>\VKI> OK I>[V«>RtKI)
'Writtin «<M-i;iI iW-sij^nation)
niKTHPI.ACK
StMt( or (.'oMutry '
NAM1-. Ol
KATIIKR
HIKTMl'I.ArK
Ol- lATMKR
I State or Country^
MAIDKN NAM)-:
<H- MOTIIKK
HIKTIllM.AOK
«U- MOTIIKK
(Statf or Country')
(^
X d-^^^'^-'^A;
Oy^v
A
a
OCCri'ATION
d^<XA>-<
Krsiifn} in Siin /â– '> iiin isf<> C)\. >Vi;;>
,1/../////'
/ilM.v
phi; ahovk ST \Ti-n i'Kksonai, i'\k rirn.AKs aki; ikik to tjik
HHST OF MY KNO\\m:i>C.K AM) HlM.IlvF
(Informant
rrw)
I \<l<lress \^K^
0 !y<i\\.\X^oJ
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH /'^
La
(Month) ,f
„ n
(Day)
(Year)
I HIvRI-BY CERTIFY, That I attended (leccased from
lL\^UCL iX 190 M to LLa^<vXIL. \1 190 H
that I last saw h -^ â– ' alive on LL<,^c^ . 190 '\
and that death occnrred, on the date state»l above, at J I 0
Qs M. The CAl'Sn OF DI-ATII was as follows:
.A^.
or RATION )'fafs
CONTRIBUTORY
Months Days Hours
:Y:\:.\..\Ay^
DURATION Yiuus Mouths Days
(Signed) Uj^JU[vwvvv VL.oJsAjj^yi
yiv^Q 11 iQoH (Add res
ClAL INFORMATION
V
-V^l^tl iqoH (Address) L
SPECIAL INFORMATION only for Hosi)ltals, institutions, Transients,
or Recent Residents, and persons dying away from home.
Hours
M.D.
\
Hew lonq at
UsuTReTidence 503^ IdJ^i 01 Piar e orOeath ? '"^ Days
Wlien was disease contracted,
if not at place of deatli?
I'l.ACK OI" lURIAI.OK RKMOVAI,
I)ATi:of niKlAL or RKMOVAI,
rSDKRTAKFR J\X.ULjL^ OO O^Ct^' , V
190'i
N. B.— Kvcry Item of InformHtion .hould he c«rcfu.ly supplied. AGB should ^T-'^'^t^^'^^''^'^' ,Z^^'^lo^^:^'':^t
•tate CAUSE OF DEATH in pinm term., thot it m»y be properly cla.s.f.cd. The Special Information for p.r-
aon« dylnft away from home Hhould be ^iven in every Instance.
\ '
ID
» t
m
\ I
« •
rfiSEjw
ii ^ 1
}
V
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
H 'nn
1 ,,f lliiillh !•■No- I'
*?^^
HS:l' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
lOO'i
l)((lc Fih'd , Llo^QA^^^'fc 1^
,Kj^ Xlom^ Deputy. Health Officer
Registered JSTo,
" 4 « i ^
DEPARTMENT (ff PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( "CI. S. SfanDar^ )
PLACE OF DEATH: — County of Oou^v^ O.^.OLy>vC^<i,5(City of O /CX/^^ ^ AXXy>AyCAA.e<;
-M
No.
St.; S Dist.; bet.X'x/VM.^baAiAx) and d/C/CiAlv)
/ ir Oe»TM OCCURS AW*Y rPOM USUAL RESIDENCE give facts called for UNDER "special INFORMATION- \
V. IF DtATM OCCURRf D IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME
II
V
PERSONAL AND STATISTICAL PARTICULARS
DATK <H- lUKIII (\ h
[..nth I \ (Day) (Vt-ari
AC.K
•J
Vtiii
Mnuthy
ai
Ha 1 .
^IM.I.K, MARKIKI)
W IDnWF.I* <»k I)I\(»krKI)
Writf ill sotial <U«i!.'nati<)!i)
MEDICAL CERTIFICATE OF DEATH
DATE OV DKATH
(Day)
I go
(Year)
(Month)
I HI;KI<:BY CKRTirV, That I attended (leceasetl from
/La-v<CU l^v iQo'i to Uo^
LU-v<CU i^- iqo'i to Uo^^e^^ l^ 190H
that I last saw h ahvc on VAA^^..AX_ > ^ up \
and that death occurred, on the date stated above, at v3
LIm. The CAISI-: UF DIvATII was as follows:
a,
A'VOw'^'XA^
X--Ofcr
r>\.
iKiMii'UACK n QC\
l:it. or Couiitrv^ X ^(J I ' ^
NAMK <H-
i"ATin:R
lUKTHI'I.AOK
Ol- I AllUvR
'Stall- r)r (.'oiuilry)
MAIDKN NAMK
Ol- MOTIIHK
lilK'nri'I.ACK
01 MoTMKK
'St:itf or C«niiitry>
ore r I' AT ION
jJULxxx/wo^ .
kfsitirii in Siin J'ldih/M'n
)'fii I
^h'llths X. \ ^^'':'
TMi: AliOVK STATKD I'KRSONAl, TA KIKT l.A KS A K I", TKIH T« ) THK
iiHsT OF MY KN()\vi.Kn<".K AND ni:i.n:K
'' : ljO/cJlLA...C^t.
r\<l dress .
DTRATION Years
CONTRIHl'TORY
Months
Days
Hours
Dl'RATION
(SIGNED )
)'citrs
i
^font/is
Davs
T90
'X^QLAX
Hours
M.D.
'■—
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from liome.
Former or "»**' 'OM «^
Usual Residence Place of Deatli ? Days
Wlien was disease contracted.
If not at place of death ?
I'KACH Ol- HIKIAF, OK KKMoVAI,
fiA^o Uu^<i--''
ITNDKRTAKKK W^ \I R^ \l J^^
(Address I 0. 5 ^ \(\\^Jii^^.JyL â– \
DATlvof Ml HiAi- or RKMOVAI,
LLCVXX l^ I90H
IS. B.— P.vcry item of Information .houlcl be c«rofully Huppllccl. AGH nhould ^e stated EXACTLY . ^"/^'^J^^^^l^J^^'^^^
state CAUSE OF DEATH in plain term., that it may be properly classified. The Special Informat.on f.r pT-
Rons dylnft away from home should be ftiven in svory Instance.
'.M
.. . », 1
Ir
«»^
i
f
\
W
li
1
I
Vdl*..
t,
WRITE PLAINLY WITH UNFADING INK
^Wt-nllh !â– V.
-ft.'?^5*^;-, !!X: 1' (*
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
l)((li> Filr(l , \Xk.ajOAJ<aX) 1*^
lOO'i
JRe^istei'cd J\^o,
10T8
\jo^>u Dep.M.ty.Ms.» ' • »' .Off - - r
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( "CI. 5. t5tan0arC> )
-?
PLACE OF DEATH: — County ofOa. , O/va/YvCAXi.cc City of*^Wru 0 AXXy>v<MAl,C<j
^
No. C) "LvAj ^^ 0
Crvc^'VAi^LA V
a.
SU; H Dist.; bet.
and
-)
/ IF DEATH OCCURS AWAV FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER 'SPECIAL INFORMATION" \
V, IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME ^Ui\
•-i:\
DATl
\<.]-:
PERSONAL AND STATISTICAL PARTICULARS
COI.OR
RTIl
ctWr f "^5 ^"
Mciitlil
oJ.t
Hi
I ),./'
Day)
M.'iitif
i Vtai'i
n,n.-
^INt.I.I* MARKIKl).
\\':t' 1 ;i '.ocial (li>-i>.';»atii)ii )
I'.IKTIIIM.AOK
' State or <.""initr\i
N \MJ-: ()!•
FATIIHR
IMKIMPI.ACK
<M lAl'UKR
' Mat( or Country I
^T^iIll■■.^• nami".
"! MoTHl.K
lilKTHI'LACK
«»!•• MoTHKR
(State or Country I
OA-^Li/^-X^.
MEDICAL CERTIFICATE OF DEATH
DATE OF DICATH
(MoiitlO i\ (Day)
1 HI:R1;15V C1:F<TIFV, That r attendcil (leccaseil from
• — ■\i)0 t(i ' — — — ~~ — — up
tliat 1 last saw h alive on — — — — — — — -up
and that death occurred, on the dale' stated above, at
M. The CArSI';_()l' Dl'.ATH was as follows:
CL/>vi
d
A-V-A^
/CA,^iL
^r^^^trVATYV
"1-
.'v/^^^CrVA/^-V'
IXVyvxO^
n
yjnuth^
/),n
<»i Cn-ATION ^ j
f\f--i\lrif ill S,;>r /'i i! n, /^■•o J, \ )..;.
IHI-: A HOVE STATin PHKSONM, I'A K llCf I.A K S A K 1 : I" K T K To 11 11-:
JiKsT OF Mv kn()\vij:i)(;h and nv.ijy.F
InfMiiiiaTit
r\<l(lre'is
HS-'X
^Ow^^^^c^wr
VjV OwX-^-v^Axv o h
I )r RAT ION )'i'(irs
CONTRIIU'TORV
DURATION ^ y't-ars
1^
Months
Days
//ours
Mouths
(SIGNED )..Lt5U-
,.. ^.ftlulL..
Pays
vcL
//ours
M.D.
inj
ULt^a 1^ TQo'i (Addre-^s) L<r\^-Ul^vO Li.^t'-^^-
oalTn
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
Wfien was disease contracted,
Former or (,
L'sual Residence A ^'
Place of Deatfi
Days
If not at place of death ?
VI XCl-: ol' lU'KIAI. OR ri:m"\ai.
l)Aâ– p,^..! liruiAi. or RI-:M<>\A1,
l^ i9o'i
IN
Dl.KTAKHR ()vD . VJ . ^^ Ji^X/^.AJL^^
(Addresv
.Htion should be cnrcfully HuppU.d. AGE should bo ntnted RXACTLY PHYSICIANS «hould
ATH in pl«m terms, that it m,.y he properly classllfied. The Special Intormat.on for p.r-
!^' B.—— Every item of Inform
state CAUSE OF DE
sons dyinft away from home should be feiven in every instance.
'1^ i
!«»
S
i
M
If
m
k
WRITE PLAINLY WITH UNFADING INK
\< iMTcfiifWtStttt— ^f*^ ?»s.
/)(ffr Fi /('(/,
.lefi^'v
?% I>C. I» fr\
THIS IS A PERMANENT RECORD
RFFPR TO BACK OF CERTIFICATE FOR INSTRUCTIONS
n
lOO'i
Be^ififercd Xo.
1079
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( H. 5. 5tan^Ar^ )
J?
J?
On
No.
PLACE OF DEATH: — County ofOOyrv' J,\.c«-avCvaco City of ^O^^r^ O 7vo^vvc.v-ilci
oJfcAUl
(XKkju^
St.;
Dist.; bet.
and
/ IF DCAThAoCCURS AW*i FROM USUAL R E S I D E NC E G I V E FACTS CALLED FOR UNDER -SPECIAL INFORMATION" ^
i, IF Ot»^H OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME VOA^^i^ cUCkaj
-1 \
PERSONAL AND STATISTICAL PARTICULARS
! COI.OR
^oL
!t xTi: i)i' r.iKi'ii
\ «■.!<:
M..titlii
H4 ),./;> â– "
il):tv^
M ,„th
I Year)
IKi\
^iNt'.i.K. M\Kuii:n.
'\ MX twin OK i»i\"ttK<'}:i)
1 -'niiil (Ic'^iviiiitioii)
i;iKTiiPi,.\ri<:
^titt or (.'Diintrv'
NX Ml-; <)l'
i".\tim:r
lUKTHI'I.Ai'K
ni- lAlllKR
'Statf or C'otintry)
M \iiii:n XAM1-:
'>! Mo'l'HKR
IMK I'Hl'l.ArH
t'l' MOTIIKK
(Stat- .1- Country^
OCCMl'ATION
c
/Ou^^\^<X'
rvTv^^^o^'A.'
MEDICAL CERTIFICATE OF DEATH
DATK OK UK
i9o\
(Year)
(Month) (T (Day)
I Hi:Ri:r.V C1':KTII<'V, That I attciKUMl <lc(vase<l from
LIaa,Q_ lb KpH to LL\-v<v 1^ H)OH
that I last saw li-^ • ^ alive on LLa^*^ i I 190 l
and that death occurred, on the date stated above, at 0 xo'
LL M. The CAISK ()!• DIvATir was as follows:
.. \
u
kXV\j
I ,ni, I ^ri>
);â– .;>
\r.,,iih^
/),M
rm- MJOVK STA'Pl-.I) PKKSONAI, I'A K'II<- r I,A K S AKl'. VRVV T' • I'll 1%
H1-;ST OJ-" .MY KNOWIJ'.IX.K AM) lUlIJl'.l-"
X'Mrcss
I)rR.\TI()N ' )'i'ai
CONTRinrTORV
Moni/is I)a\ 'S Ho n rs
..CVX.OC <i/o. 'v r^^txj. .
}
nrRATION }'r(irs \ Months Pay!;
(SIG
wCaj
//ours
M.D.
LvMX\.\H TqoS (Ad.lress)dfe.\J/LQAxyi ()V'&-^vt.
FECIAL INFOR
Special information only (or Hospitals, insnfutions. Transients,
or Recent Residents, and nersons dyinq andy from fiome.
^'roJ(OLcL->^NycC ^-o-^Piare of Death?
Former or ^q
Usual Residence
Wfien was disease contracted.
If not at place of deatfi ?
Days
ri.Aci-: «>i luKiAi. OK ki:movai
vJoJ{00cv>'
T90H
INDl-.K fAKl'.K
(.\d<hcss
DA 11; of III KiAi. 01 ki;M<»\AI,
^. B._Hv,ry Ue™ of l,„„.,n„,io„ .houl.l be cnrefuMy ,>,pp.U,.. AGB »h„.>,l bo ..aUH EXACT1.Y P"^«''='^^~« f ^^
8totc CAUSE OF DRATH In pinin term., thni it m..y he properly cla.-.tied. The !,pe..al Intonnat.on for p.r-
«on« dyint awny from homo ahouUl be (Siven in every instance.
I
V \
w
I i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
„,;).fn;i!th f No u^^^H&rCo REFER TO BACK OF CERTirtCATE FOR INSTRUCTIONS
i\
Dale /v/^^/, GLuvo^v^t \.H 100 ^
Registered JV'o,
1080
.'0â– \.A-^^^
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
( "a. S. StanJ>ar? )
PLACE OF DEATH: — County of
ro
>'"W>L/cLou City of VKJL'\)<X.\jCXu6^^ L<X'
No.
(\r DEATH OCCURS AWAY FROM USUAL
IF OtATH OCCURRED IN A HOSPITAL
St.;
â– Dist.: bet. and
RESIDENCE Give FACT
OR INSTITUTION GIVE I
TS CALLED FOR UNDER "SPECIAL INFORMATION" "X
TS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
JU:.
:y\aa^.
SKX
PERSONAL AND STATISTICAL PARTICULARS
I COl.
I.OR \ f\
\xXl'
\Ti: nl- I'.IKIM
Get
iMiMith)
U-
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH
(Day)
L\aa.<
(I)MV)
(Veur)
'^ ' . !•:
I J 1V.;;.> I 0 .!/.»////> I ''t
/)(; vs
â– ^INt.I.K MARK n: I)
W IDOXVKI) OR DIVdRCKI)
Write in s<Mial <UsivMi;iti<>ji)
luk rm'i.AOK
(Statr or Country'*
h.
N'AMH oi-
JAIUKR
lUKTHI'I.ACH
f>I I AIHKR
'State or Country)
MAII)i;x NAMK
<»» MOTMKR
HIRTHl'I.ACK
OF MOTHHR
'State or Countrv)
••'■eri'ATlON <^
Q
(Mouth) A'
I mCKl'IBV CI-iRTIFV, That I atteiKk-d deceased from
(Year)
190
to
190
that I last saw h nr— alive on v ■..■- 190
and that death occurred, 011 the dale stated above, at —
M. ^hc CAl'SK OP DJvATH was as follows:
O^J
V
\^s-^u^^
(«
DrRATION }'ears
CONTRIIJUTORY
Mouth a
Pays
Hours
<XJ^^ -^â– â– >rUU-\j
t^e^idfd in Stin /> d in imU)
) '»■<; ; ,
Mn„ths
l>nr
diration
(Signed)
Years
Mo fit /is
Pays
TQO
(Address) MLJLL^ LoJL'
Hours
M.D.
SPECIAL INFORMATION only for Hospitals, Instituflons. Transients,
or Recent Residents, and persons dying away from home.
'"nt^J•r^y^.^''"'^ ''♦■■'* ''HRSONAI. FARTIC F I.A RS A R I-; TRFK TO TIIK
"F.srOF MV KNOWI.KDC.K AM) HKMKF
(Iiifoiniant
O^xJLu >^^kj^WW^Jir\y^Oj^ 4^JL^.yv>^vtr
fAddress
#
Former or
Usual Residence
When was disease contracted,
If not at place of death?
How lonq at
Place of Death? Days
FI.ACH OI- KFRF\1. (►R RF:M»)VAI,
I)ATF:of Hi KiAi. or RKMOVAl,
a A^^ I90'i
CLa^O i^.
d. u). t). i - Ujla^vocUvu ^
FNDFRTAKKR J ^KX/0-<Wv oU.AULaJK^ ^
(Address S>.5..1>. \ryV\.^i^o.^^A. .3;^.
IN. B.
•Kvcry item of Information should be ciirefuily Aupplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH In plain terms, that It may be properly classified. The "Special Information'' for psr-
Anna ^..!_A e l • ... .. • ..
«ons dyin£ away from home should be ^iven in ms^ry instance.
' I
!
II
il
J* •.
^4
iri
>
i
11*1*
u
( «
>
Ir
«
I
i
Moil 1 1
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
,, ,1. iith I N ' i^»^Sg^H&»'Co RCFCR TO BACK OF CERTIFICATE FOR INSTRUCTIONS
l)(ff(' Filed ,
H 100 "{
Registered J^o.
.^vv^ ds.L/x>A. Deputy Health Officer
DEPARTMENT OF IpUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( xa. S. Stan^arD )
PLACE OF DEATH: — County of CIcl/yv O^CUivx^U-cCity of "OAX/yv OAXX/rvCAAxto
St.: 1 Dist.:bct.
(IF OCATH
\r DC*
' s*.. 1 L)ist.;bct. v I wu./^^AJYAJ. and 0 /CU.{/L^
OCCURS *WAV TROM USUAL R E S I O C NC E G I VC facts called rOR UNDER "SPECIAL INrORMATION" "X
ATM OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
^'W)..
PERSONAL AND STATISTICAL PARTICULARS
s,.:x Qjp
nXTK «)!•• lUKTII
C01,()R
C
U
19^ \
(Year)
10
(Day)
\ ' '. K
\ >•(! I
Mi>n//i.>.
(Year)
/hi vs
^IN'.I.K MAKKFKI).
WIDoUKI) OK DIVORCKI)
'N\iitt iti S(K-ial <l«->jit^iiati<)ii)
1»IK ruPKAOK
(Stutc or Coutitry^
NAMK OF
FATHKR
THRTMPl.ACK
Of lATHKK
(State- or Country)
MAI1)1:n NAMK
Ol- MOTHKK
lilRTHPUACK
OF MOTHER
(Stato or Coiintrv)
VJ.CL/W 0
MEDICAL CERTIFICATE OF DEATH
DATE OK DKATH ,'^
LW) il
(Month) T (Day)
I 1II':RI<:BV CICRTIFY, That lattendcMl deceased from
LLcM^r *^ 190'i to .. LLwA^ {%, T90 H
that I last saw h Ji-hj alive on VwAAAX:l iX 190!^
and that death occurred, on the date stated above, at 10 o.v
CI- M. The CAUvSK 01- DlvATH was as follows:
nrRATiON
CONTRIBUTORY
}'^ars_ ^ I\fonths J^ Days ^ Hour.
DURATION
) V<7.
OCCrPATlON
fffsidfd ill Siin I'liiiiiisro
) '/â– (/)
1 Months t) Por.
'^h
AFont/is o Day.
Hours
(Signed) .oU U .\X'\nyv\-<i M.D.
LiAA.a lliqoH (Address) iOlb M^^VU^ilX at
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
How lonq at
Plare of Death ? Days
Former or
Usual Residence
' "«T^J!I?^^^ STATKD PHKSONAI. PAKTICIKAKS ARK TRIE TO
«KsroK MY kno\vij:d(;k and hkmkk
% \x). Jj^^-\^^\..<yxx "d^
THK
(Info
iinant
(Address
When was disease contracted,
If not at place of death?
PIJ^CE OK BURIAL OR RKMcUAI,
UNDliRTAKKR
DATKjnf Hi KiAi. or RKMOVAI.
la I90H
(Address
i ^- -^
o-'cUto^A.^'
N. B. Every Item o? information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
•tate CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special Information" f©p per-
sons dyin^ away from home should be (iven in every instance.
I -
'4
?1
t •• ♦
. 1,
m
A\%
!l if
)l
,M
! w
i
It
Hi
i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Board of M« alth- \' So. k
H&l'Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/hf/c riJcdrS
cUcrLA^ui d'
IS
lOO'X
Registered JSfo.
108J^
Dep"^-''igrvhOmcer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
( 11. S. StanDarD )
PLACE OF DEATH: — County of
City of
tpwou
No.
St.
Dist.; bet.
and
(IF DtATH OCCURS AWAY FROM USUAL RESIDENCE GIVt FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET ANO NUMBER. /
FULL NAME
â– \
!».\TI-; OI- lURTM
ACK
PERSONAL AND STATISTICAL PARTICULARS
I COI.OR
.UAv\Jaj
\. (lb Cr\^vcx.>^cL
iMotUliI
(Uav)
MntilliS
SIN«.!,K. MAKKIKl)
M IDUUKI) OR niVOKCKI)
Uiittin »i(Hial (lesijjuatioti)
IHKTHPl.ArK
'State or Country)
NAMK Ol"
lATMKR
HIKTMPI.ACK
<»»■I'ATMKR
(State or Ooutitry)
MAIDKN NAMK
<)»■MOTHKR
IHKTirPr.ACK
<H- MOTHKR
'Slate or Countrv)
/â– (Year)
Da r.v
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH
(Day)
190 \
(Year)
I in<:RP:nY CI<:RTIFV, That I attended deceased from
â– â– â– â– "â– 'â– ' 190 " to •••' â– 190 — ""â–
that I last saw h •.^:~~~ alive on ■" it^ rrz—:
and that death occurred, on the date stated above, at ~~ â– â–
M. The CAl'SFi OF DHATII was as follows
jb X<X^vjt .A-.^C^aJL:
A»,.w.NJL,
DURATION Years
CONTRIBUTORY
Mouths
Days
Hours
OCCUPATION
Hfsidfd in Siiti I'l am ist't)
(SIGNED)
\.KJ^^\ IX \qo
:!-
Mouths
(Address)
Hours
DURATION Years Mouths Days
Al....]cL.l.MU^v.Hl>-t\/>x^ M.D
k
FECIAL Information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
) V'<r;.
M,»ith<
Da\.
THK AHOVK STATKD PKRSOXAI, PARTICrLARS ARlv TRIK To THK
JlKSroF MY KNOWMCDC.K AND BKMKF
(Informant \l fCOLA/tl^V VJ . LI. jJ^^^V^tX
(ArWrrrss
L a , i/i)
\
XX'Vuo
Former or
Usual Residence
When was disease contracted,
If not at place of death?
Hew lonq at
Place of Death? Days
PI.ACE OF BURIAI, OR RKMOVAI
rXDKRTAKKR \w'<X)Wr'fc'V/"i"*-AXX; - > T"
tlres.s ^ H.C). S. Cfo-V^.^-ciL .y±..
(Add I
■^^ **• Every item o? information should be carefully supplied. AGE sliould be stated EXACTLY. PHYSICIANS should
•tate CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for per-
sons dyin^ away from home should be ^iven in every instance.
SAX
•:i
11
7
â– I
\
t1
I ' 1 V\
1!
\
'i > i i^
(
t
V
r*<,
â– : i * I
I 1
J'
I I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Hojik! ..f llr;iltll- »•■No I«,
H&PCo
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Ihf/^' Filed, [\ju^'u<^ l^ 100^
\j:r^A^\jiL^ Deputy Health Officer
Registered J^o,
.108.3.
DEPARTMENT OF PUBLIC HEALTH=Clty and County of San Francisco
Certificate of 2)eatb
si
( "a. S. StanDar^ )
'5^
J
%
PLACE OF DEATH
: — County ofCJo>/YV 0 AXLAAXAACcCity of O /CL/^-^ OAxX/YVCl\Aac
No. V.OLV
.-K.^v
'tr\.\,oxLu
C^
U\.lI
O.'/.St.
Dist«; bet.
and
(ir DCATH OCCUnS/kwAV FROM Usual residence give FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
IF DEATH OCCUI^CD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
Uj
0
PERSONAL AND STATISTICAL PARTICULARS
^i:x QC\ ^ I coi,()R i'^
Ox
»N I H Ol- JMKTH
Oc^H
a,
Month) A
\ « . I",
0 6 IV,;; V D
â– A. <J\
(Day)
yhniths
(Year)
VO. ^.V>
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATM ~~1
lL
(Month) A
AX
(Day)
(Year)
ai
nii\.
^IN'<.I,I>:, MARKIKD.
WlDoUKI) nk DIVnKc HI)
Uritiiti sfK'ial rlt.si;.rnati()n)
lURTMIM.AOK
'St;it« or Country)
f-ATHKR
RIKTHPI.AOK
n|- FATHKR
'State or Coiijitrv)
MAIDHN NAMK
'»»■MOTHKR
niKTHIM.ACK
OF MoTHKk
'State or Coiuitrv)
I in<:RnnY CIvRTIFY, That I attended deceased from
LLv^^a ^^ i9o2> to .LLaw\^ l.l 190 .H
tliat I last saw h rVv alive on LVx^^^/Ol 11 190 ;
and that death occurred, on the date stated above, at 1 0 30 .
LL M. The CAUSR OK I)I':aTII was as follows:
k^'\ v.A^<X
]'dars
w
Man (/is b Days
1
(
i
DT RATION
CONTRIRUTORY .J..AA.<CA..^..^.\^<i....j
r'Ui/^'V.ec^
/)avs
hVsiilrd ill Sun /'i an, i.^nt [ )V<?;.v
.^rniiffi.y
I\l\
DTRATION Years Afont/ts
( SIGNED ) J... Aa. dt) OL>vt'
Llvva itiQoH (Address) Ljtu,^ L^.
tt
Hours
M.D.
o-<..(.J:..
SPECrAL INFORMATION only for m\>M%, Institutions, Transients,
or Recfnt Rrsldrnts, and persons dying away from home.
Former or How ionq at -v^^-e^s
Usual Residence Place of Death ? io Days
When was disease contracted,
If not at place of death ?
' "l^^!V?^'^ STATKD PKRSONAI. PARTlCrLARS ARK TRFK TO THK
ISF.SI OK MY KN()\VIJ-:D(;K and JIKI.IKK
(Info;
nia
N. B.-
nt U ) rWu Vf /\ d^/CXOLTUjV'
< \.i(ire s LaXu/^ ^ nD O-Cilxlt:
I,ACE OK BIRIAU OR RKMoVAI. I DATK of IHriai. or RKMOVAI,
^D _ igoH
INDKHTAKKR
(Ad
dress. ^.lol^X' \^ kk^AAk,
<X-'CVCXy>'V^
-Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for psr-
Rons dyin^ away from home should be ^iven In m\^vy instance.
*ITI
!
M
Hi
Hi
« »
N
i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFtR TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Boai.l nf IKnlih I" So. 1 «; •^x'wj^i US: I' Co
/h,fr Filed, (XlaXm.4^ 1<^ . . lOO'A
d^^o-^^x^^ dUL/v~u Deputy Health Officer
Registered J\''o.
1 f^'^i
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of E)eatb
( "U. S. GtanC>nrC> )
Ji «p
.fd
A
^
PLACE OF DEATH: — County of^<X">^ 0 AxiAv<:.\,<i/c>t City of OO-oaj 0 Ax«-/yvca.o,cc
No
.1111
^
.VA.\.K
St
.; b Dist.; bet
Uc/vuXj and ^-^J^^XCUwWyxx)
(IF DEATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR uVl D E R "SPECIAL I N FO R V ATI O N '• \
IF DEATH OCCURRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEHD OF STREET AND NUMBER. /
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
'"'A A -^ ft j coi.oR
\^}
XUJb
i'ATi: Ol' I'.IKIll
\' .)•;
(l)av)
fV.;ir)
(Yf.'ir)
Tl
) r.i
a
.!/..;////>
11
/>.t ) .^
WrDOWKl) OK l)I\»)K(Kr)
Wiitiin siK-ial lU si.^Miatioii)
I
i'litlt-
»
'â– â– IK'TlllM. \i*l-:
St.iti (ir (.â– <nnili V
I A I- III.; K
lilKllll'l. \i]-
Ol" iAriii-:K
' M.iic 111 r.iiiiiti vt
"I Morill'.K
niK rin'i,\ri.:
«M' MnTil|.;H
'Siati- (ii ('(iiiiiti \
Uaxtv-v^c^ (TV dLx.
ftAEDICAL CERTIFICATE OF DEATH
DATi-; Ol- i)i:.\Tii 1^
LLla^O I'i,
(Month) iT (I)ay)
1 HlvUJvHV Ci:RTn<V, That r attende.l deceased from
IwLuL .1 icp'i to ...LIaaXV i% Kp H
tliat I last saw h A.WV alive on LCvvQ l*t 190'^
and that death oreurred, 011 the date stated above, at 1 1
LL .M. The CAISI'! OI- Dl-ATI! was as follows:
Cj^/W./O^-x'XA.AlA.-trvv.
A^'YV
^-^^rvvAXO jUUL/vv<iX
oMr^A-VtX/
OL/'^X/W
(?
i)ik.\'i"i().\
/)<ir.'
Hon
lUvi
> V C UC» % \j
)'cars \ Moil //is ....,.,.,
It /is
\j , jULo^o-JOs.
Li^UuD I'l looH fAddnssHllt Ja^.>Jk
f^avs
//ours
(Signed) \j, JULo^oxXsXKx^ m.d.
I'l i()oH (.\ddrrss) lilt OA^.>vk dt:
SPE<ilAL Information <»nly for Hospitals, Inslilutions, Transients,
or Recent Residents, and persons dyin-j iiway fro-n home.
'•'■^■ri-.\Ti()N (^ P /'j)
1^1, 1,-, f III ^,1)/ /'i ,111, lui) .l)\ij )Vi;/v • l/.'i/'//.
/',/1
Former or
Usual Residence
When was disease contracted,
If no! at place of death?
Kow lonq at
Place of Death ?
Days
I '1', \Mu\-,.-, sr\|-i:i) I'HKsoxAi, I'AKrim.AKs Aui; i-KrK to Tin«:
"i.M ()(■• Mv K\(»\\i.i;i)(,j.; \\i) Mi;i.n;(-
ri.ACK oi- HjLi<i.\j. OR ki:Mit\\i
M m
I)ATJ\<if lit i:i.\i. or RIvMoXAl,
^^^'r:^- _j-^ • 190 'X
(Vi li 1 % ~J^ ^
rM)KRT.\KKR M I - U /VCXa^ M. \^
(Address
.JkuJuiUik
K. Kvepy Item of 1nformntlon Hhoiild be carefully supplied. ACIB should be stnted KXACTLY. PHYSICIANS should
state CAUSE OF DEATH in pinin terms, that It mny be pr«M>eHy classified. The "Special Informution" for per-
son* dyinft away from home should he feiven in every instance.
I ,
II
I
«
11
m
»l
\ i*
iti
.4i ;
V
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Bnar.l .'f U<iillh- F No. I «, ^»^
H&J'Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dafr AV/fv/, iXv.x^^ 15 l'JO'\
cL-CrV-AA^5
Registered J^o.
1 085
Deputy Health Officer
DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco
Certificate of Death
( "CI. S. Stan^arD )
PLACE OF DEATH: — County of'
vJCUTU OACLAVCAACcCity of 0/CWu J A/X/V^Xl^-CjXl^
Na
3C) 0 VJ ,axT^,\Ot. J Ju'v^<u (IbiKkAistI' ' S Dist.; bctmU^cJkxXmXXA^ and XouQA^y tXXi )
(ir OCh^H OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ A
IF O^ATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / (J
FULL NAME
â– ioaA/. !
SK\
S»AT1-: OF niKTll
Ai.K
PERSONAL AND STATISTICAL PARTICULARS
I coi.
%
Mouth)
^Xc't_o
XI rllX
(Day) (Year)
MEDICAL CERTIFICATE OF DEATH
DATE OF DHATH
' ' il..
(Day)
190 'i
(Year)
I HHREBY CKRTIFY, That I attended deceased from
LAjoM
a 190M
11
CS c*v ) ra f > cK
Mouthy
1\
Da n
sixr.i.E. markif:d.
WinoWKD OK DIVOKCKD
'U'lil* in s(K-i;il drsiv^tiatioii)
lURTflPKACK
(State or Couiitrv)
â– ^
m
*ii
NAMK OF
FATlUiR
inKTHI'I.ACK
Ol" FATUHR
(State or roniitry)
MAIDKN NAMl-
OF M»)THKR
hikthpuacf:
of mothkk
(State or Country)
^Cr \..l I90M to UU.AX3L i.^ 190 H
that I last saw hi — -alive on LAw^-^a lb
i.'l.
1
190 I
and that death occurred, on the date stated above, at iV
s| M. The CAUSK OF J)1{ATH was as follows:
^.y:^JUu..\i^.\/y.^
OCCUPATION f^ DO 4.
tuj- VUt^uH
DURATION Years ^ Months
4.'ONTRII]UTORY
Hours
Days
J ^
DURATION Ye^rs Mouths
(SIGNED) (b. "u. OA.<.>^(hu£
"r^vUX;
f\r\idfd in .Stiti /'laniisfo
)'ra
., R
.\ro,iths
Da V.
Days I i Hours
M.D.
"^"'.^M!!.^^'^ STA'-KD PHRSONAI, PARTICILARS AKK TRIK To TMH
15F.ST OF MY knowij:d<;h and hki.ikf
(Inf.
>rmant
\JL\^
%
Ua.VX>....1^ TqoM (Address) i b i 0 U/gm^M U^.-^ LLvn
Special Information only for Hospitals, institutions, Transients,
or Recent Residents, and persons dying away from home.
Usual Residence ^'H'i) (lb OAXXAxt dil Place of Death ? 3.
When was disease contracted, , ^ } }
If not at place of death ? b /YrU)-0 -lMt|t.\i.
Days
PI.ACK OF Bl'RIAI. OR RKMOVAI,
..^SX^\.\j^XXL
DATF; of lU RIAL or REMOVAI,
.IXs.^ ^.0. 190 . ^[.
rNDF:RTAKKR Q ctVcUl'vv U oJaj?^ LL^xxLo \^^<j
(Address .
ii>,^,
^' ^' Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information'* for per-
sons dyin^ away from home should be ^iven in every instance.
iij
i:
H
i -f
IS
I:
I
\
m
'ilil
I .
Ilii
' f
'li,
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I1...1V ! ..f Ihiilth «•■So. n >^
HM'Oo
nCFCR TO BACK OF CCRTIPICATi: FOR INSTRUCTIONS
II
Dafr AV/^v/, Uaaxxv^ IS IfJOH.
Registered J\^o,
1 nc^6
^rr
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Death
( Ta. S. StanDarO )
PLACE OF DEATH: — County of ^/d/^v JAXLAa/CA.<L/C< City of w/ay>^ \j K/yy^r\Al.^,^lSl.<i
^P^ VwA.
~ Dist.; bet. and
A / ir DEATH occunsAM/AV rnoM USUAL RESIDENCE give facts called ron under "special iNronMATioN- \
\J V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME
.coyvru
SKX
l»\ 1 ». «»l lUKTM
\ â– . V.
PERSONAL AND STATISTICAL PARTICULARS
I COI.OR
l)L)lv-K'
Uxm
(Month) r
n
IDav)
M.mlhs
(Year)
O
Davs
SINi.l.K, MAKKIKI)
\vri><»\yKi) OR nrvoKcKr)
iWiitfin s(Hi;il <l«»iiKiiatiuii)
niKTHJM.ACK
(State or Country)
-i^
di
NAM!-: ()V
» ATin;R
HIKTHPI.ACK
<>l" FATHKR
(State- or Country
MAIDHN NAMK
<>l- MOTIIKR
lUKTHPLACK
<>l- MOTHKR
(State or Country)
OCCri'ATlON
C<L^aJ-/YV
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATU ~j
vXc^n IJd.
(Month) K (Day)
I IIIvKHBY CKRTIFV, TliaW attended deceased from
M«u_ .Q»..Si 190 H
190 \
(Year)
I90H
that"! last saw h.^<- • < i alive on AAA.
and that death occurred, on the date stated al)ove, at ->• «L0
UjM. The CAUSK OF DICATH was as follows
DURATION Years 4 Mouths Days Hours
CONTRIHUTORY
DURATION ^.
(Signed) J ,
Days
(Address)
vC<
Hours
M.D.
^<l\:X:
Llv.\.Q \% 190'i
SPEcIpaL Information only for HoMtals, institutions, Transients,
or Recent Residents, and persons dying away from fiome.
How long at .
^>-vuUL Place of Death? X\ Days
Former or
Usual Residence
AAXa^x^lJkv
AVsnirtl in S<in I'niini.uo ^O )><;;>
M,»ifhs
Da « ,
When was disease contracted,
Ifnotatplaf' 'death?
"".;A!?i?^'^' STATlCn PHRSONAI. PAKTICri.ARS AKK TRIK To THK
HhST OK MY KNOWI.TCDC.K AND HKMKF
(Informant
lO^.^.lc^l
<>^|
. .TO (^-oAv^-txX
Pr,ACE OK h RIAI, OR RKMOVAI. I DATK of HiHtAi, or RKMOVAI,
0 -1) H % % ">
INDKRTAKHR >J\JLA.VA^ "*<^ OO O-OL^Q^VU
(Address 3>b..rLX - . l^ .Itl.. 'Jl
N. B.-
-Every item of information should be carefully supplied. AGE nhould b« stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information*' for psr-
Rons dyin^ away from home should be fiven in •s^ry instance.
-
li
1^
?;
t â–
i
.(III
ill:
m
'(I
J.vi
t .1
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Hrwird of ll(alth-K No. Il^ '5^
»& V Co
REFER TO BACK OP CERTIFiCATC FOR INSTRUCTIONS
Da/r hied, U.o.xxia^ i"^ ^^^"1
d^<y\ju^ dJU\>^^ Deputy Health Omcer
Registered •A^o. X
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( 'd. S. Stan&arO )
J? Of? J?
H,
PLACE OF DEATH: — County of JO/YV 'A^OAvtM^cc City of ^J^CU>\^ v) /v<X/Tvt:.A^ cc
0
fffO
1'
No,
(ir DC
IF
/CU">vJw<X.Vu„<y\i St.; --
ATH OCCURS AWAY FROM USUAL R E S I D E N C E CI VE FACTS CALLCO FOR UNDER "SPECIAL INFORMATION" '\
DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
Dist.;bet«
and
FULL NAME
.OU^C^
U/ci\J!x<juUL\j.
PERSONAL AND STATISTICAL PARTICULARS
DATK «>|- HIRTH
COI.OR
X^'JxuJi
iMoiilh)
ACK
11 IV,;; >
(I):iv)
Mnul/if
A^5
(Vcari
MEDICAL CERTIFICATE OF DEATH
DATK OI' DKATH
' ' A.O Il
LLl^
(Month)
'\
(Day)
igo
(Year)
U)
Daxi
^INC.I.K, MARKIKD.
W IDdWKD OR nrVORiKD
'NVritf in sm'ial iU'sit.'nati<)n)
HIKTHFI.ACK
(Stittr or Countrv^
NAMK OI-
lATin:R
lURTHPI.ACK
OI- lATIlHR
'St.'itf or Country
MAIDKN NAMK
OF MOTHKR
inRTlII'I.ACK
OF MOTHKR
(State or Country)
>Uvou:L
I HBRI<:nV CI<:RTIFY, That I attended deceased from
,\.^^^JL A.l) 190H to UwA^V^....!.^ 190H
that I lavSt saw h ^^*\.! alive on
190'!
and that death occurred, on the date stated above, at o
VV M. The CATSH OK DIvATII was as follows:
U <X'<iX/\./^'^ VwOLA.yCx^:^c'v.<r^yW/OL/
DrRATIOX
) '€(V'S
Mouths Days
Hours
CONTRIBUTORY "^ 0..<dLNJLaL(rv:^^.'U UAA/a..ijQ...llC.\..
Years
Mouths
XTPATION (>p |\
DURATION
,NED)ILll'U.dM^'
vAA^Q ll 190 '\ (Address) ^y\^>.-^k 1 1
(SIGI
Days
Hours
M.D.
SPECNXL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from liome.
Rf.u'dfd ill S(7n Fiamisro Q.Q. )V(M «
MiHitlis
n,i \y
rm: AIJOVR STATIM) PHRSONAI, PARTUTLARS ark TRIK TO THK
«Ksr OF MY KNOWKKDC.K AND HKIJICK
(Informant V] |VV) V' O /^iXxA^Vt- \\)
Former or
Usual Residence
Wlien was disease contracted,
If not at place of death ?
How lonq at
Place of Death? Days
190H
PLACE OK BURIAI, OR RKMOVAI, I DATK of Bt'RiAL or REMOVAI,
itndkrtak^:r Oo. 0 0^a..*^W\j ^^ v<)
(Address
N. B.
Every Item of information •hould be carefully supplied. AGE ahouid b« stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information*' ffer per-
sons dyinft away from home should be ftivcn in every instance.
fi
I
i I
J
\
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
Mn.ir.! ..f iiciitii- I'No. i«i •<^2^wi)n&rc<)
l)(ffe Filed ,
o^jyu^y<J^ (kJi/\.
\%
WO^i
Registered JVo.
1088
Deputy Health Officer
DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
( XX. S. StanDarD )
-^ m
A Qi)
PLACE OF DEATH: — County ofOa/>\^OAXL^\<^UULC City of Ocl/vu JAX>yvy^c.A^<LXit
No. H 0 Uc/UJ^^^i' cL<X/-^\^<L' St.; ^ Dist.;bct. I^Wxi^ .l.tiJ.\; and ^crLr>oL^ .)
(IF DEATH OCCUnS AWAY FROM USUAL R E S I D E NC C G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" 'X
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
.. U C^V'CL^C.ii
^i:\
I'Al i; Ul JtlKTH
\ ' •. !■:
COI.OR
(\f|>nth)
Diet-.
y\Jb
1 V4; I
(Day)
M'luths
/HO'l
(Year)
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH /"^
(Day)
7pO V
(Year)
%..
190
H
^ 'S
Da ys
>^I\«".Mv MAKKIKI).
\\Il)<»\yKI) OR DIVORCKI)
Uiittiii MH-ial (Usiviiatioii)
MIKTin'I.AOK
(Statf or Country^
N'WIK <)»
1- athi;r
inkTMI'I.ACK
<>l" lATHKR
< Statf or Country)
â– ^lAIDHN? NAMH
<»I- MOTHHR
lURTMPUACK
<»K MOTHKR
'Statf or Country)
oCCri'ATlON
(Month) \
I IIHRKUY CP:RTIFY, That I altciKled deceased from
Lix-ua \"1 190H
that I last saw h^' alive on \_/v<v/v<va„ ■^ i^o
and that death occurred on the <late stated above, at b-v)'
CL M. •n..CArS.01M.K.VrM«.asasfo„o«.s:
U 0^^j^.AA^^rv"u<r"nwA.X5c \1) A/Ct^vC'K.a.^cl.I
a
D
I)r RATION Years
CONTRIIU'TORY
Mouths 1 Days Hours
DURATION
Years
Kffuifd in S(iH /'lanriyro "" )></;.< 1 .yfoiithsJs.^ Pu
^fontfis
(J
Days
A^> iqo^ (Address) 2)'^'^
Hours
M.D.
'k
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
Former or
Usual Residence
Hew long at
Place of Death ?
... Days
r.v
' "V;.^'!1*^'^ STATKl) PHRSONAI, PARTICTKARS ARK TRIK TO THK
IlhST OI- MY KNOWI.KDC.E AND UKUKK
(Informant
dlxLcx^-A^ d
O^Ou^i^'tiX)
^\<l<lress
When was disease contracted,
if not at place of death ?
PI,ACK OF BURIAL OR RFIMOVAI, I DATK of HtKiAl. or RFIMOVAI,
(.\d(lress 15 XH, O X;^KcJ<lX^rV\. . .0.1.
IN. B.
^vcry item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" far psr-
nons dyin^ away from home should be given in uscry instance.
f
I .
t \
â– t(i
1 •■11
♦
1,
'I
(!
*^t
II
I** ,
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
p., Kit. I. f Ilr,iltli-»-*No. i^ *'^"»]J^v)lUS:l'Co
1)1 lie rih'tl ,\Xju<yOA^<^ ^S
Deputy Health Of:i-er
Begistei'od A'^o.
lOr O I
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( "U. S. StanC»arD j
PLACE OF DEATH: — County of CJ/CLO^ 0 AXXOvCA^CCCity of ^Wro 0 AXX/vvCv<L/t^<.
IVo,
t
')^A
kdal
St.;
Dist.; bet.
and
(IF DEATH OCCURS
IF DEATH OCCU
s awa|^ from usual residence give
RRED IN A HOSPITAL OR INSTITUTION GIV
FULL NAME
FACTS CALtED FOR UNDER "SPECIAL INFORMATION" \
fE ITS NAME INSTEAD OF STREET AND NUMBER. /
11
')
Cii'uxv.l^'^
i:\
PERSONAL AND STATISTICAL PARTICULARS
I'Al i: (•! lUKlH
iMoiilh)
.\<".K
3?^
5 'I'it i
Day)
M,.„lin
(Year)
Pit 1
•^INJ'.I.K. MARkll-.I).
W'liti-iu social di si-.-natiini)
I
r\'\^y\ 'V\. tj ^^Jr \
H
P.IK I'm-i. Aoi-:
Stall or t'l mnti \-
WMi: <)i'
iatiii:r
IMR TIlI'l. At}--
'>' I Aiin.:K
'Siiit( or roniilrv
"^lAIIiJ'.N NAMl-'
''•I RT III' LACK
<>1- MoTUHR
(State or Coutitrvl
OCCri'ATiox
MEDICAL CERTIFICATE OF DEATH
DATr: nl- DllATM
It
(Day
01.
(Moiitli)
/] (Day) (Vi-ar) I •
I INvklvl'.V CI;RTII'V, That I atteiKiod deceased from CZ^
,v^Lu 2.x 190 H to. LU.va.ilo 190 H ^
tliat I last saw h r> \' alive on LUwVOl I'c 190
and that death occurred, on the dati.- statt-d above, at H-3v.O.
(T
M. The CAlSlv Ol" DICATII was as follows
Sx^vt LLL<l ' ^ ^ ( 0 ir>
r
'j:
m-QAi-a.,
J
)<v7r.?. Mouths Days Hours
CONTR ir.l'TOR V ^-V^^_^^AJL^XO..t-<r^x...frj^^^^
u
M
Dl'RATION
(SIG
M.D.
M'>;>h^
/',n
I'iU'. \UoVK S'r\l'KI> )'KRSoNAI, I'A RIUM' I.ARS AKI", TRII-: T< ) \'\\V.
•iKsT()i-;^v kn()\vij:i)c.k and iu:mi:f
)'cars Afoul /is 1 Pays 10, Hours
NED) V\m\n^
cIaL Information on'y for Hospitals, InstjUuMons, Transients,
Special information only for Hospitals
or Recent Residents, and persons dving anay from home.
Former or ^ . ^ ^% M ^4 ""*^ '<'"•' ^^ i
Usual Residence vO V W d OAAJJUO OI Place of Death ? b
When was disease contracted,
If not a\ place of death?
^
Days
Informant 0/V/OL/>aJ!^ VJL\.'<M'
A^XX/V^cL<l^<J "> V'
\.i,ir.-.s Hot. vj jxxxajlL'u "8tj
•I.ACi: Ol' lU R;.\I, OR RICMoXAl,
•NDHRTAKKK vL UJ- v)rto.vl^^»^/^..L:j
(Address 3) 1 H vj 0 OJV^JLlL>L; ol.
i)\ri;o: mi kiai. fu rhmovai.
190H
^- B. Every item of inforrrmtion uhoulil be cnrefully supplied. ACiB shoulil be 8tate<l F.XACTLY. PHYSICIAINS should
state CAUSE OF DEATH in pinin terms, that it may be properly classified. The "Special Information" for per-
sons dyin^ away from liome should be i^iven in every instance.
V
r
tfc
[
i,
I
« z
ii' = 1
i
,1
I
« >..
1
»,
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Ikunl nf ll«;iltli »•■V«) 1=^ '^^^^H.S:!' Co
l),ih' Filed, lL^\AAtj 1^ VJO H
XLv-u Deput
Registered ^o. ,1,09.0
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
( "d. S. Stan^ar^ )
PLACE OF DEATH: — County of ^-JCLAvOj'uX/Yur^ULCO City of UCUrv 0 AxX/>X/C-c^c.c
No,
.lb
It
ChAl,'
Kd.
<X
St.
Dist.: bet.
and
(ir DEATH OCCURS KwAV FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
cm. JLuOj. C5\.'
FULL NAME
^\
u^o
PERSONAL AND STATISTICAL PARTICULARS
S)"\
fluU
C(
DATK ni' niRTM
.\..|.;
\U.LAJU^cr
Month)
(Dav)
O JL 1 lii > V
Mmitln
(Year)
Da 1 A
MEDICAL CERTIFICATE OF DEATH
DATE OK DKATH , ""i
(Month) if
I HIvRHIiY Cl'RTIFV, That I attended deceased from
.1.1
(Day)
190 \
(Year)
190
to
tliat I last saw h r— alive on
190
190
MN'.I.K. MARRIKD.
WIIXIUKD (IK DlVoKiKD
Uiitriii s<Hial <i»-sij.'iiatioii)
HfkTm'l.ACK
'stiitr or Cotintrv)
iatui;r
HIKTMPI.ACK
f>|- FATHKR
Stritf or I'onntrv)
OI- MOTHKR
HIKTin«I,ACK
<'l" MOTUKR
(Statf or Cotinlry)
'^'^-V,^
and that death occurred, on the date stated above, at
M. The CAl'SK OF DIvATH was^as follows
..kAAAJL..,,<'\^ .sJ..<C>-<<j4.\JL.-.k.VXU:Utj.> . 0^
AAraW,
3vX\JC>-Cr*%
'•rcil'ATlON
Kf^idfi{ in Stin /â– ') t!ii( /u<>
-L wet'
^\.Oj
DC RATION years
CONTRIIUTTORY
Mouths
cU
Days Hours
Dl'RATION
Years
Months
/Mrs
\ â– ^Jj.UJ.XiLLcXyvvdL
UX> li ic>o't (Address) Lt'UryxXA^-:^ U^^^;.
ECI'AL IN ' â– ^^
( Signed )....UJ'Ur\\j2A'
a
Hours
M.D.
Xy'U^
SPECIAL INFORMATION only for Hospitals, Institutions, Transifnts,
or Recent Residents, and persons dying away from liome.
Former or
Usual Residence
How long at
Plare of Death ?
Days
)V,;
M.-ntln
n.i
' "'.;.^'!9^'^- ^TATKH PKRSONA!. I'AR'f IC TI.ARS ARK TRTK TO TUK
HhSl OF MV KNOW IJvDC.K AND nKIJi:F
"f-Mmant It) KA\, 6fc ()t (y^^UATtoJu
When was disease contracted.
If not at place of death ?
fi
'\.l(i
rrss
IT^ACK OF BFRIAI. OR RKM<»VAI, I DATKof HI'riai. or RKMOVAI,
^ -i H % % ^
INDKRTAKKR JVi^AAAA. ^ (J \D /CXXytX^yV/
(A.Mr.ss. Sb.lk^ \'\k)J *dt
N. B.
Every Item of information ahouid be carefully supplied. AGB should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information*' f«r per-
sons dyin^ away from home should be (iven in every instance.
IS' i|
«i '
I
5 â– ;.!
'^
J'
.IBTT
f^
â– 1.'
« I
I
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
M.„. ! t II. alt). I No .^ ^-^E^HSii' <„ REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
Ihilr FiJrd, \Xx^^^J^ \^ 19 0\
Registered Ko,
fOOl
VA^
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( "U. S. Stan&ar^ )
PLACE OF DEATH: — County of CJxXo^ JA.a.'>Ayev^,c< City of Cj/ClaX' JX/OLO-veyUL/e.0
r^. ^X/:K.rr<kj
^^tAj'X.K^
St.; — — ■— ^Dist.; bet.-
and
(ir DEATH OCCufs *W«V FROM USUAL R E S I O E NC C Gt VC FACTS CALLCO FOR UNDER "SPECIAL INFORMATION * \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
â– )
(?i1
FULL NAME
(1
PERSONAL AND STATISTICAL PARTICULARS
IN /A - A I COI.OR
I' \ Ti: o|- 111 KIM
\f, K
\ I »
X I L.'J.A-
(Day^ (Year)
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATII
-<-Q i.i„
(Day)
: Month) {{
190 'I
(Year)
Hb lV,/#> 1
Mouths
H
n,i\
SI\<.i,i.:. MAKKIKI).
W n)(t\Vi;i> (>K IMVnKrKI)
Writ! in social <lc>iij.Miiiti(»n)
MFKTmM.AOK
fStatf Df Coimtrv'
(^
oui;
NAMK (>l-
I- XT Mi: R
HlkTHPI.AOK
Ol- I- ATI IKK
State or t'ountrv)
MAII)1.;n NAM}'
01 MOT I IKK
HIRTMPF.ACK
}>»•■MOTIIKR
(State or Country)
(3?
.OLA-vL^n
^\JLu
I4.II':Kl{IiV ClvRTIFV, That I attended deceased from
-^ to LU..vOL...I.i IqoH
t
190
that I last saw h A. > alive on
LvXA^
and that death occurred, on the date stated ahove, at D
LI' M. The CAl'SH OF DJvATH was as follows:
vuV^wULtUx-U. O'.
' <X.A.tL^rW\.XL;. .
I)r RATION I Years
CONTRIIUrroRV
Mouths
Days
Hour.
DURATION
\^
Years
Months
^(r^K
(Signed)
LI t^y [ L iQo '(
»EcmL Info
Days
(Address) <>^<X/\\JL
h C^^\J:.ai.
Hours
M.D.
?-.
^
r^
J
OCCUPATION
f'^'^>idrd in Sou /'i on, is,;> X i )'rois t A/,>iif/ts I .
/;,n.
SPECmL Information only for Hospitals, institutions, Translrnts,
or Recent Residents, and persons dying away from tiome.
Former or q , ^ ^A 4.
Usual Residence v)l^' dJXx.' \^-\\Xj
Wlien was disease contracted,
If not at place of deatli ?
"aj How long at
'^ Place of Death?
\\
15" (Ty-vcrr
\Ajk^
Days
"'Vi.M^'^^'P-^'I'^ '"»•"»> I'KKSONAI. I'AKTIi ri.AKS AKi: TKIH To
lu-.sr ()!• MY kn<)\vmvI)<;k AM) m:i.n:i-
^nfonnatit LU -^^^V^^O u\d
(X.l.lress ^ ^ ^ O /OuZKXXy'yy^JU^rdji
TIIH
'AJ
11
C'O^xi
PI.ACE OF niKIAI, Ok K1;m«>VAI, I I)AT}v)f Ht RIAL or KEMOVAI.
I ni)i:rtakf:r
(Address
N. B.-
-Every item of information ahould be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information'' for par-
sons dyin^ away from home should be ^iven in svery instance.
f (j 'l^ti
*
j
i
i ,
it
1
'.
11.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
II. :iltli !•■No. I', f
'"=^I?>f
^•. WScV Cn
REFER TO RACK OF rPRTIFirATF FOR I N ftTRIir.TiniM^
Registered J\'*o.
f on^
Dale Filed, (Xo^ctvcA."fc l^ 100^
.dU/v-^ Deputy Health OfTlccr
DEPARTMENT OF PUBLIC HEALTH=Clty and County of San Francisco
Certificate of H)eatb
( U. 5. StnnC>avc> )
PLACE OF DEATH: — County of C^CL^ru J A.CuTVCuic^ City of 0/(X^vu J AX^LO^Ul^cV cui
IVo. Lctu/V
)(K.ivvjioJj St.;
"Dist^bet.
and
(IF DEATH OCCUpA AWAV F R O ijl USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
IF DEATH OCCt^RRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
FULL NAME
D
LxXWro
PERSONAL AND STATISTICAL PARTICULARS
i Co I, OR
1 ol l;|R 111 0
N J
A
•f
M..nth^
H
I);iv)
MEDICAL CERTIFICATE OF DEATH
DATH Ol' I)i:.\TII
(I):iv>
CL
(Year)
^' .I':
bo )•,„;> I I Mnvl/l.^ I
Pi! I .^
"^'N' i.i" MAKk n:i).
v\ ii>o\vi-:i) OK i)ivoKi-j-:i)
'\\iitiin ^oci.'il (It — iLMiatii 111)
I'>IK•rnl'!,.\^•l•;
St;itc i.r r<)iititrv>
NAMK ()|-
!'-lk llll'I.XiK
^"•" lATHl-lR
^^AllM•;^• \\mk
OF .MoTIll-.K
"J" mothkk'
<^t.itc or Coiintivi
(Month) f
1 lIi;i<I';r.V CI{RTIFV, That I atU-n.Ud .Iccoased from
VAAA.Q. l\ iQoH to CLo*.^ \%
^O^ W
1 90
.'J
that I last saw h -'- • > » alive on
IQOS
I9O '.
ami that ilcath occurred, on the date stated above, at A- 3 0
*^S: -^f- '''J><-" CArSl<: Ol- I)i;A'riI was as follows:
^X-^vVAjdXcL^
DIRATION Yrars
CONTRUU'TORV
Dr RATION Vrars
i Signed )
crr\)
^v
OCCUPATION P 0
c-t
a
Cvq l^.TQo'i C Address)
lAL IN
Mo}iths /hirs Hour.
.'>JLK.dJkJ'..Ar^^
\ft>nt/is /hiys Hours
SPECIAL INFORMATION on!v lor H^spitdls, Institutions, Transients,
or Rerent Residents, and persons dying awdv fro-n home.
Former or lUA^iM Jj M 4 il How lonq at
L'sudI Residence I \^^ 0 CtUUav 0/aU UvK pjare of Death ? I
Days
Mouth'
I hi
'""V;,^'!,?^'»*- ^■'"\'I'»"I' I'KR'^OWI. lV\KTh-ri.\Ks AKi; \-KVV.
"l-.sl o).- Mv KNo\\ij;i),;h aND ina.Il'.t"
i<) Till-:
n
•"'"""■■".t UJrv^. VmI. X<x.a.>o4^^
f X.ldress..
N. B.
Kverj
state
Xt-vlc. obo^kAltaX
When was disease contracted,
If not at plare of death ?
I'l.ACH Ol' JU KlAI, OR K]:Mo\AI.
I'A'ij:..! i'.i niAI. .ji KJ^Mi »\,\J,
ot
1
TQO'i
(Addrc''
>■item of information «houl(l be cnrefuMy supplied. AGC should be stntcd F.XACTLY. PHYSICIANS should
CAUSE OF DEATH in plnin terms, that it may be properly classified. The "Special Information" for p«r-
Ciyinli nv%'flV from hnmn shniilil ho atiion in <>%/<>r>%^ ' • not •• nr».
sons dyin^ away from home should be Aiven in every instance.
^m
.<
i
*;
I J
V'
h
'iii
I
I
i
i
II:
III';;
Pi '
I
ii
' *WS^
\i
\i
n
^i
J I I ' : i ,
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
1 , f ii< ..i»l,--l.' Vn It ««>lltt<Ski li/C- 1' ('
/)/t/c l''il('(l , LU_A..QAA^ 1*^
190 H
to^c^ tiLa)-M Deputy Health, Officer
Registered J^o. j./>93
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Death
( "a. S. Stan^a^C> )
SI ^ J?
%
â– X 'Op -V H)l)
PLACE OF DEATH: — County of Ooyvu J XXLTUMA'Cf City ofOovYu 0 AXX/Vu-CA^ ex
No.
(IF OCATH OCCURS AWAY mOM USUAL
ir OCATH OCCURRCO IN A HOSPITAL
St
. ^
i
Dist.; bet. ^^ ^^^Uf*OJ\j and cL(.ytn\;
RESIDENCE Give facts CALLCD roR UNOCR "sPCCIAL INrORMATION-TV
OR INSTITUTION GIVC ITS NAME INSTCAO OF STREET AND NUMBER. ]/
FULL NAME Oo/^^^a^ulJ
>^xi'
PERSONAL AND STATISTICAL PARTICULARS
I
Ou^
.'Ji'A^vjtjj
DA'll-; oi- HIKTII
\' .!•;
iMoutli)
'J) H Yr,,,..
(I)av)
Mouths
(Vcar)
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATH r\
(Month)
Da I'j
^IN'<.I,K. MAkKIKl),
\VtI)(»\V}.:i) ,)K DiVoRCHI)
Uiitt ill MK'ial (l»-siKiiatinii)
nrKTni'i.ACK
'State or Coiniti v)
NAMK OI-
I- ATn-:R
'>IKTIIP!,AI-K
Of" I ATMKK
'Stntr or Couiitrv^
MAIDKN NAMj.-
OI- MOTIIKK
'nKTlIPI.ArK
OI MoTMKR
'Stat< or Country)
H
o<y\j\.Kju6.
tn>ou CJ /C<rL^^x>j
(Day) (Year)
.1 HKRKBV CivRTIFY, That I attended deceased froiii
jCLOrV. ^ I90H to AAa^^MD^..]^ i<jo*1
that I last saw h ^- • *\ alive on
^...A 190 1
and that death occurred, on the date stated above, at 1
Uj^M. The CAI'SIC OK I)I«:.\Tn was as follows:
'©^
OL^VO^
\
i.../a-y.-.i^
Dr RAT ION Years 1 Mouths Days Hours
CONT R I HI TOR V iL'xvw.^xjLVv^i.A,<o...
CLAvd^
I)rR.\TI()N
(Signed)
V
Years
Mont/ts
/CO-A^l
li<A.a l^. iqo'l (.Address) be '\
OCCUPATION
ffrs'iilfd in San J-'iamisro H H )></;» ' Months
n.iv:
-q i^t IQO \
iOIAL INFORI
/lours
M.D.
-tVvwa (J t'
SPECIAL INFORMATION only for Hospitals, InstHutlons. Translrnts,
or Recent Residents, and persons dying away from home.
' "^l.^J^*^''^.^'''*'^'''^•'' ''HRSONAI, I'ARTICn.ARS ARK TRIK TO THK
"f-.ST or MY KNOWI.KDOK AM) WVAAVW-'
(Informant NPlVUi O 0<yyy.^KjX U) ivuXcX^X^
f X'Mress
^^SH (l.v^vx di
Former or
Usual Residence
When was disease contracted.
If not at place of death?
How lonq at
flare of Death? Days
PI,A
RIAI. OR RKMOVAI,
DATK of Ht KiAl. or KKMOVAI,
INDKRTAKKR O (JVcLtVw UOlAX LL'WCt<:iX
I90H
(Address ^HV^
N. B.
Every item of informution should be c
state CAUSE OF DEATH in plain term., ^ .
«ons dyin^ away from home should be tiven in svsry instance.
ape?ully supplied. AGB should be stated EXACTLY. PHYSICIANS should
ns, that it may be properly classified. The "Special Information" for per-
mmm
•
m
< I
s*
l!l^
^i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
n,^•.^,! .,f IN mHJi I" N'o. m
ji&r Co
/>.//r r/hff, \X^uuQj(u<j^ n loo'i
Registered J\^o,
1004
Depu^'v ^'
OvTincr
DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
( la. S. StanearO )
PLACE OF DEATH: —
No. U
.cL IL
County of OOyyv JAXX'-YVCULCtCity of C /OlA\; 0 A.cX/v\aia.<L'C<o
\X>^>^<1) J^A^UX' St; S Dist.; bet. M 1 lAAA^Ura) and 0^ CrUX)L\d )
/ ir DtATM OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
â– rXX/^U
Lh..
PERSONAL AND STATISTICAL PARTICULARS
^^••■^ (JP "ft I COLOR
I Month) (Day) (Vear)
Xi
rVcX.je.
MEDICAL CERTIFICATE OF DEATH
DATE OF DEATH /I
(Month) A
n
(Day)
190 \
(Year)
'^' i-;
Id IV,;,. V 1
Mofilfis
1:1
Pa r.v
'^IN'.l.K. MAKKIKD,
U IDoUKD OK niVOKiKD f)
IUKTHI>I,AOK
< State or CcMmtrv
NAME OK
»atmi:r
»IKTMI»I,A('E
oi" iatmek'
'Statf or Oomitry)
MAIDEN NAM I"
«)» MOTHER
HI KTH PLACE
<')" MOTHER
'State or Country)
I HKRKBY CKRTIFY, That I attended deceased from
w..^ X 190 ?. to .CLa^ i.:x 190 4
that I last saw h ^\.' alive on LA>Aa^. 1 lu iqq ^
and that death occurred, on the date stated above, at
M. The CAUSE UK I)I{ATII was as follows-
0 txAAh^AjLcLV' ^..\j^iju>^sijK.. ai.:LiLiL..^jL<cL/.ut..
. \-kLL%.
VkXju
D r R A T ION } 't-ars i 0 Months 1 T Days
Hours
CONTRIBUTORY
«
UA,<Uc
Xi2y>\Xu
CLvAi
DURATION
(SIGNED)
-L{pr\^A'\XcLuccct;
occrpATioN J n n A
Vfsiifnf ill San /â– 'niii,/J?ti | I, )',,// v
)'r(irs Mouths Days
SPEC^L INFORMATION only for Hospitals, institutions,
Hours
M.D.
or Recent Residents, and persons dying away from home.
Transients,
Months
l)ii\.
'"i;rJ'r*y7.'^J^ '''■•" J'HKSONAl. PA KTICC KAKS AK E TRIE To TFIE
i'EsroF MV K.NOWl.EDC.E AND MEI.IEF
F n
(Address II O A^XX/^^cL \Xj
Former or
Usual Residence
Wlien was disease contracted,
if not at place of death ?
flow long at
Place of Death? Days
\>^„
ri«ACE OF RFRIAI., OR KEMoVAI.
DATE of Hikiai. or REMOV.^I,
\^/\^<y^ :) Lu.,x^_^ XC) J 90^' \
INDERTAKER M ' V \iKry\^>r\, ^^Kjy^'
-t
(Address ...
ixu Ofla'CUUL^tL^it
N. B.
Rvery item of infnpmation ahould be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information** fer psr-
«ons dying away from home should be given in svery instance.
^1^1^
I -J
, \
i
i â–
t
(
1
• »
n
• I
^.i
uu •
it 1
WRITE PLAINLY WITH UIMFADINQ INK — THIS IS A PERMANENT RECORD
WiarMcl lliaiin I- .-^lu. i> -»-^z"ggjH»^pi m.x i v.«*
REFER TO BACK OP CERTIPICATC FOR INSTRUCTIONS
/)(f/i' Filed ^
la
lOO'i
Registered ^''o. \.9.D.D
Deputy Health OfTlcGr
DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( \a. S. StanOat? )
PLACE OF DEATH: — County of OCLn^ vJACL/^ruiAA^lx^City ofO/CX/ru JA^0l/>TX1c^c.Ci
â– No. ntU \iri^-^^c<nv St.; S Dist.;bct. 15^ .fcn. and \ikl\
/ ir OCATH OCCURS AWAV FROM USUAL R E S I D E NC E G I VC FACTS CALLtD FOR UNDER "SPECIAL INFORMATION" ^
v. ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
11
• n
)
FULL NAME
o^Va^l
Uu
XAA,^^jy\j
â– i,\
PERSONAL AND STATISTICAL PARTICULARS
I COI/)R
0.
I»\ 11. ol- HIRTH
<xXx
Uj>lviLv
MEDICAL CERTIFICATE OF DEATH
I Month)
\ ''.»■:
t 1 lV,/».
(Dav)
Motith'
0-. •
(Year)
Da I .s
'^I\'.I,K. MARklKl)
WIIMIWHI) OR DIVORCKI)
'\\rit. in scH-ial <lcsiKnation)
lilKTMPI.ACK /-\ « .
(Statfor Country) (^ \ P
NXMI-: 0|.
lATHKR
"I k Til PI. AC F
'>'â– I ATHKR
iStatr f)r CountrN
MAII»i:n NAMl-
<>1 .MOTIIKK
'ilKTHI'I.ACK
<•»•" MOTHKR
(Statf or Countrv)
'»* crpATiox
%
DATE OF DKATH /O
Uxu:i
(Month) k
X HHRKIiV CI':RTIFV, That I attemlc.l .lecca.sed from
So. igoH to LAaA.
tliat I last saw h ••
..^UwA^OL i:
n
(Dav)
n
igo^K
(Year)
190 H
alive 0!i LAwC^Ol 1 1 itp '(
and that death occurred, on the date state<l above, at 4
v.: M. The CAl'SK OK DI^ATH was as folIf)ws:
....X.qJw<v.
.t„v.L
^i^ . ..i
"i (S^V H d^CLM/^ . .4AA>Xy»A.^->-v>i.'
-i \.^ V
Tv
DrRATION Years Mouths \nays Hours
CONTR IIU'TORY U Xd/. .LL.C
T
> ud..
Hours
DURATION Years Months Days
(SIGNED )...\Lri. U. xXxajlLa^xj M.D.
II iqoS (Address) ?)?) ^ (0 - R jj^, -^^t
CL/'y^cL
M,H,tln
/hn
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
'"nvc'r^y.^- ^7"^ '"'■•" ''HRSONAI. I'ARTICn.ARS AKK TKIH TO TIIK
Hhsr OI- MY KNOWI.KDC.K AND HHMKK
(Address
Sll
N. B.
cUhx
Former or
Usual Residence
When was disease contracted.
If not at place of death?
Hew lonq at
Place of Death? Days
PLACK <)I niRIAUOR KFMOVAI. I DATK of IJi kiai. or RFMOVAI.
.'V-t
1 : R T A K K R <) ^rLAjo-v\j a <xtx Uw-^ V<3Lo
I90H
(Ad(
VI rLv;CyCLA..<rv
^^fcry item of information •liould be carefully Hupplied. ACjE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in ploin terms, that It may be properly classified. The "Special Information" for per-
sons dyinft away from home should be ^iven in every instance.
1 ♦
T
11
I
\
I
mm
. 4
<m.
4T
L^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
1 ill .. 1 * t. i; N'-*
.^^gf^'V .
1 ) C. I i f *
-t ••%«.•
MfehtM ro HACr\ OF CERTIFICATE FOR INSTRUCTIONS
IS wo\
Deputy Health OfTlccr
Reginlcred J^''o.
f 0^>fj
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of E)eath
( â– a. S. StaiiJar? )
PLACE OF DEATH: — County ofOoyro OAxxyrvCAA,<Hi City of CVq-a^ 0 Axx^-w^cA^o^tjc,
St.; Dist.; bet. and
/ IF DEATH OCCURS AWAY TROM USUAL
(IF DEATH OCCURS AWAY FROM
IF DEATH OCCURRED IN A H
RESIDENCE GIVE facts CALLtD FOR UNDER "SPECIAL INFORMATION â– \
OSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
1 coi,()k
Vyi/YV^-lJLAj
:l
\i
A li-: (ii KiKi'ii
iM.-ntJi
as
) 'ii I
(Dav)
M.mlli^
Mat
(V.-ar)
Da
MEDICAL CERTIFICATE OF DEATH
DATIC ol' nivATII
a.
(Month) K
(Dav)
I go 'i
(Year)
^INt.I.i:. M.\RRll.-l>
WIDnWKI) (»K niVoKri:!)
'\\i iff in ^.K-ial di^ivMiatinii)
'Slatf or Comitry^
\ WW. oi-
I- A III j;k
-i ^
JWULO '
I IIIvRllHY C1{RTIFV. That I altcn<le<l (Icccascd from
\^^Xu 11 190H (() LLl.i/ql .11 T90 H
that I last saw h^i^nv alive on vJ>wVA-a \'\ ^p \
aii<j that iKatli occurred, on the date stated above, at il
!^ M. The CAISI- C)l- I)|;aTII was as follows:
"iK'nn'i.ACK
"!â– I-AIHKK
I stair or Cdiuiti v'
MAI1»K\ NAMJ-
<»)• >toTHKK
"IKTHi'i.ArK
'»;•■MOTHKR
'Slatf nr Coiuitrv')
'^x.CrWrvv
DC RATION Years (o Mouths Days I /ours
C 0 N T R 1 1 ! r T ( ) R \' U^X^uCt(rruJ:AJ^ J JuJLL^/<iA,AjU. H. a.
Days
II'ATIOX J.
^^^^ f^rsiilnl in San /'i ,rii,is/-,i " )'>,r/< O .1 A ;â– ///>
)?(7rj U, Mouths
N ED ) fc . M ; UxLcUjUl.'CL.'L<
I'i rqoH (Address) 5^0 5" ^AAJMnat ^1
DI'RATIOX
(SIG
Hours
M.D.
5^
/>r7).
"nrJ-r'^T-^'"^'"'''* '•'^•HSONAI. I'A K T IC T LA K S AKi: TKIK To
'5'-SI OI- Mv KNOWI.l-nC.K AND Hl-I.n-f'
Tin-:
fliif'Tiiiant
'Address 5^0 5 i)x.v.j^.^AX CJI
Special Information only for Hospitals, institutions. Transients,
or Recent Residents, and persons dying awny from home.
Former or i ^ /s [ \ \ \\^^^ '^"1 ^^
Usual Residence iOO VXXXUrCx yuvol atpjare of Death?
When was disease contracted,
If not at place of death?
3(.
Days
I
I'LACI-: OI" IHRIAI. OR RHMoVAI,
I)ATi:<)f MiRiAi. or RHMOX'AI,
INDl'.RTAKKR LAj • LU VI Fl/X^jX^^'^VV. ^<^ L^O
r
fAddrt-ss
N. B.
Hvepy item of iiiforitmtion should be carefully supplied. A(jB should be stated EXACTLY. PHYSICIANS should
state C.4USE OP DEATH in plain terms, that it mjiy be properly classified. The "Special Information" for per-
sons dyin^ away from home should be feiven in every instance.
t !
1 '
mi
â– i
r
'!â– %
• ,»
I!
«
â– i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
II 111. • • V
> .-- -ft---- -?, ..:. II V- l> (>,.
ncrtn iw i3M«-r\ ur utKHKiCAfE FOR INSTRUCTIONS
/)((/(' F/7r(/, U^^LA^xiyu^o^ ICi
Jf)0'i
(y\A..\^
Bcgii^fci'ed J\^o.
J097
'A
Deputy Health Officer
DEPARTMENT OF'PUBLIC IIEALTH-City and County of San Francisco
Ccitificatc of IDcatb
{ "U. S. 5tanNuC> )
PLACE OF DEATH: — County ofCjCL/w JAXI/^XCoiCc City of C' CLA^ 0 /VCu-^^ca^Ic^o
St.;
Dist.; bet.
and
/ IF DfATH OCCURS Afl/AV FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' ' \
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER )
FULL NAME
I'V^'V
^.
'cL
o:i
PERSONAL AND STATISTICAL PARTICULARS ^â– '
i "I I'.ikrn
' Month*
MEDICAL CERTIFICATE OF DEATH
DATK (>1 I>i:.\TII ,o
IS
(Day)
^Moiitli) /'
(Vt-ar)
\'.).
1,1 \'
M.nitl,^
l\t
'>vii». »u i-:i) UK i)i\c)Kti.:i)
' \\'l itl- ill -n(i;il ,1, v;.f.,.,ti,,,,)
'niitr\i
.ucLct^amAj
NAMJ-: OI-
''â– IK'I'HI'I.ACH
Of' i-.\rm:K
MA1I>I:N NAMl-
'>!•• M()Tm:K
J5iiniiiM,\c,.-
iStiilc or c"(>iiiiti\t
^A.
c».
I III:RI:15V Ci:kTn-V, That ^ allvn.lc-.l .lecoascd from
tli.it I last saw li •■- alive oil vAwV\,/Ct, 11 Too S
ami tliat <loatli orrunt'd, on tlic «latt- stati'd alx.vL- at 5
y .M. TIu- CArSI-M)I- l>i:.\TII was as follows:
^v^C
I )r RAT I ON I Yearn X Month
X
CONTRIP.rTOkV
c
^rotlth}
ocerr.
/\f'lifrif ill Siiii /'i III/, rr.i c*^^ '
(Signed) j /^vcn^^ou-i
a
/hJVS
0.
/>ays
Hours
//on
I )r RATION' i )V,/r.?
J /^VCrv^^ou'i ' 7.^r\^^>v<X.^v M.D.
.U^O X\. r<,o 1
JaL iNFORi
f
SPECIAL INFORIVIATION only tor llospildls, Institullons, FMnsienls,
or Rpfpnt Rfsidpnts, dod persons dying dv^jy fro:n homp.
lA'/z/Z/v - /*,,
•n'sroi Mv KNOW ],i;i)(,i-: and i!i:i,ii;i-
formpr or
Isiidl Rpsidencf i H :) X^j O/Vy^^i) Vct'vu) Uuf i^re oi Dfdth ? 3 0
lioH long iit
Days
Whpn Has diseasp ronfrac Jpd,
If nof at plarp p f dpath ?
(I
'f'>nim„t lij . (i . "jU./>-.J[>^
\-l<ln-ss Xl.5 ^
:::u
/<x-\^X jXj
I'l, AC}-; < »1- ]UKIAI, (»(^ kl.M«i\AI,
HAD-; ..! Hi Ki.vi. oi Ki;M()\-,\f^
TQOS
fA.Micss
' • * fivepy Itom «.>• iiif )rmiit!on should be cnrcfully suppl5<.<l. AfJIi Hhrmld be Ktiite*! r.XACTI.Y. PHYSICIANS Hhoiild
stntc CAlJSn OF DI:A TH in plain terms, thjit it mjiy l>e pr<.pcrly cluHsiried. The "SpccinI lnJropmiitt(m" for pep-
sin* riyind "wny from home should be l^iven in every instfince.
m
»!
II
â– f
f ' t
'VI
j 3 I'l
m
\h
''f
^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
* « - ncrcri lu ciMur\ OK CtRTIFICATE FOR INSTRUCTIONS
I)ff/r riled, LWxx^v^ ^0 100\
Deputy Health OfOcer
RegLslered Xo,
1098
DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco
Certificate of ©eatb
( *U. 5. Stanc>aiC> )
PLACE OF DEATH: — County of LAXa/vv\JU:LcL City of
^
J /vAA.AX^^oJLX' LxxX
No.
St.; Dist.;bct.
^5T1^
r " °"":" OCCURS AWAY TROM USUAL RESIDENCE give facts called for under "special information- \
\ IF DEATH occurred IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
lA
FULL NAMEvrU
\Xk}
CML.
i ^wA^
'^v/cLoV^xn-\'
PERSONAL AND STATISTICAL PARTICULARS
rnl,(»K
JL
j\\.OJb
â– I I'.IK I'll
\)\^kX)
I NToiiili)
)',
H
IS
* I):iV>
M^.utll^
4 fit I
MEDICAL CERTIFICATE OF DEATH
I)\ri-; ol- DliATH
(I)av)
( Month) /"
I
1 in{RI-:nV CI-RTJI-V, That r attc-n.kMl <ltHvase<l from
(Vcai)
■S^ /„,
4
\ litOUKI) OK I)I\-(>Kri;i)
111 sociril ih Ki^'iiatioi! I
'â– â– IK rui'i.Aci-;
M'ltc or Ciiuiiti y
\\M1 <>!•
I Ai im:k
'"â– I \rin-K'
â– ' .â– .inti\i
M\II>1<;\ NAMF
'" MOTIII'IK
I^'KTlll'I.ACl.-
OI" MOTMHK
'^t.-it .1 r.,niifrv)
"' * I f \1'1<)\
1 90
tn
tliat I last saw h ■- — ~ali\c on _ —
aii.l tliat (k'ath orcurreil, on the date stalid ahove. at -
~ 'h^- l'^^'"' ^■^^'^^'' ^•'•" '^i: \'l'n was as follows:
190
190
y^i'^'K!
Aji\AJsy\j
DC RAT I ON Yearn
C"()NTRini TORY
Mo}itlis
Days
//on IS
1)1' RATION
(Signed )
)'(\7rs
Mouths
/Xns
(0 '
/fours
U)W^UAJ M.D.
O.C i(,oH (
A.hlrtsv,) U.CXyVLLou^vdw v^. r
Special information «nl\ for Hospitals, instilufions, Transients,
or Recent Residents, and persons dyin-] .may fro.ii home.
A'/'. /,//â– ,.' /;/ Siw / I .;/,,
)V-,r
,lAu////«
'•' --l ')|. MN IsN<)\\ij.;i),;h ANI> Hl-I.Il'F
Former or
Isual Residence
Wfien was disease ronfrarted,
If not at plare of death ?
Hgh lonq at
Plare of Death ?
Days
1M,A(.1-; ()!• ItlKIAI, OK k};Mo\ \I, j I )AI"I%_t.f IUkmal m ki;M<»VAl.
^'•'''•■'^'^ 0 h^^^AXX/\><)<JJL L^CuL
^jrvAX'
â– ^y^iJ (^../Ow-A-A^f-', \^
i9o'\
'?, I
A^
Aaa./W'v^->v '^ Lc
V^^u<r-V V
N. It.
-ivery item oV infopmiit W.n Nhould b.- »;iiroY'iilly supplied. A(IF. K^oiild he Htnteil F.XAC TI.Y. PilYSiCIAISS hHouIcI
Htntc CAlISi: OF- DI^ATH in phtin tcriiin. thnt it mjiy Ik- properly cluHsilticii. The "Special Informntion" for p«r-
Ron« clyinft away from homo should be aiven in every instnnce.
I '}!?
I !
i iW E
h
I
I
Hi'
lfl»
1
^'
•J
'i»
f ^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
*1
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
1099
XAr^.^..^^ S<ju\>\jL i-^eputy Health Officer
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Ccitificatc of Scatb
i ^^ J
(Jl^
No.
PLACE OF DEATH: — County of 0/a.'>v ayUX'>\A^iA^cCity ofO,<X^v 0 AxX-N\'C^iL-ec
T \\ d\XtA^^^c t. St.; 1 Dist.; bet.U^^U>Jul andMlV^ltaM tlv •)
( "^ ,7*1" OCCURS .w.y TROM USUAL RESIDENCE cvr tacts CALuro tor under 'srecal intormation \ if T ^
V .r OrATH OCCURRCD ,N A HOSPITAL OR INST.TUT.ON GIVE ITS NAME .NSTEAO Or STR t ET AN D N U M B t R ) d 0
FULL NAME oL',auLM. iJ (rwdx^^c
PERSONAL AND STATISTICAL PARTICULARS
07) A i COI.oR
I'ATl-: (•! liIKTil
t
V^C<,k_
©^
iMoiitli)
, "^.l
Day* (Vc:ir)
» <':ir I
l-x
S
M- MAkun:i)
'* -" >Ai:i) (»K i)ivi)krj.;n
Ml >..H-i,-il (It sivMi.'itioti)
lilKTlll'I. \k'\:
iiiiiti \ I
NAM}- (»l-
I atiii:r
niKTiii'i.An*
'>H^ iatiij:r
'Statfor Coiiiitrv"
MMI.i:\ \.\M}.-
"' M'>i"Mi:k
''•n<Tin'r,\cK
'WO.
-Oj
MEDICAL CERTIFICATE OF DEATH
i)\Ti-; oi- i>i:ath /"^
J HI:RI;1',V Cl-:kTll'V, That I alu-ndrd .Iccoased from
\Xkj^ X ic^oM to CLvux i% iQo^
tliat I la^t saw li • ' alive on V,Aaa.<T^ \\ iqo';
iiiid tliat <K'at1i occurro.l, .>ii llio date statocl al.ove, at ^
'W '^''" ^^AISI-: Ol- I)l-:.\Tn was as follows:
1)1 RATION }V.j.9 JA.;////,. Day, H J/onrs
CONTRir.rTORV 0<X/^t>v<i L/>^tcA,vtvv
'*' ''^•^'''^*''' 0 r\"'/^ ^ Mouths Pay, Hours
(Signed) i. 6j . vb.CLava^cx.^cU ^u m.d.
pecIal infori
Special information onlv for Hospilals, Institutions, Transients
or Recent Residents, and persons dyinq .mjy from home.
.lA.;////'
//.
'".M <)!• M\ KNowij.-ncK AM) iu;m!:k
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How lon<) at
Place of Death ?
. Days
A^-0^/>x\>vrv.
Uo, B:
I'l.ACK OF niRIAI, OR RHMo\AI. I r>Ari-:..r KiKiAi, ..1 R]:.M()VAI,
.very Item of ln?orm?ition should b^ capot'ully supplied. A(7B Hhniihl be stnted KX \CTLY. PHYSICIANS should
state CAUSE OF DEATH in pinin terms, that it may be properly classified. The "Special Inforuiation" for per-
sons dyinft away from home should be ftiven in every instance.
I
il
. â– f
tf fli
#
V ^v
r'l
•^jgg- WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
-*â–
r Jtentth-'t' Nn. n v-v.-wi w*,; riiv r r. â–
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
b
Ihf/c n/rd , LAAAX^LAAfc 3^0
liJO^
lt('(^i,s(('i'p(l J\^().
1100
,>0-^^><^A>0
Deputy M
-- f *
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of 2>catb
PLACE OF DEATH: — County ofOO./^^ v) AXX^-vcuicCity of 0 CCoaj J /L/<Xo've/oa.c,o
No.
/<xCurV\j
4-
^1^
Ch-<lK^ Va.l St.: Dist.; bet. - -— and
f l|t DEATH OCCURS AWAY FROM |U S U A L R E S I D E N C E G I V E TACTS CALLED TOR UNDER •'SPCCIAL INTORMATION ' \
V (J ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
FULL NAME V l^lcuva^xKjdj l)
PERSONAL AND STATISTICAL PARTICULARS
i
i
^J-^./»^^oJLx
i;!K rii
Llx'
Si
! I 1 \ I
X\o
; I
i'
' l.J". M \kUIK!)
'' "-ij-'lKil :
â– itr or Couiltl \-
Ml
I atiii:r
ISIKTHpI.ArK
â– t.'iiiniti\-
NfAIDKN XAMj.-
'-K lill'I.ACI-:
' *'<il1 lit ! \
w .
Ox-wcJoL
rXAjtx
1
A,t*-«J-
MEDICAL CERTIFICATE OF DEATH
I' All', Ml- I>i:a TH .-^
'Muiithl K (Day)
I III-RI-P.V CI-;KTI1-V. That I attcMuk-.I ik-ivascl from
UL»^VO r^ uyo'i to (Xla.Ql l^ up 4
tliat I last saw Ii .-•-.. alive on L\A.a^D i6 im''.
aii.l that death oi-rurrcd, on Ww date statL-d" ahovc. at "^
Ja ^r. The- CAISI- (>!â– â– I)i:.\Tn was as foll-.ws:
<xXvv/CL,^'^
/ -\JCL\.^
'O^'^Y^CA^
I )r RAT ION I }\ars
CONTRIIM ^()RV
I)^K.\TI<»^â–
JAv///^?
/''./j.v
/\n
MnvcL/>voc'\l ' loJury\ji>.,
J
i; 1 f
»ii.^
r \'i ii ).\
( Signed » H^1X^ (ft), ax-upv^^wv-
LUcQ 11 T()o's r\ddns.) Ho^3) -aH.tL Bt
EGIAL INFC
Special Information «nly for Hospitals, Institulioas, Irdnsienls,
or Recent Residents, and prrsons dvin.j dWd> fro.n liomf.
Former or lo^^ Ai+f "^4- How lonq at
L'sual ResidenceoO OA " ci^H ^C^Vv O.t Place of Deatli ?
i
Davs
"â– ^â– ' 01- -MS kn')\vm:i)<-.h AM) i5i:mi:f
r.iint
.^\JL\^r'
When Has disease tonfrarted.
If not ^\ plare of deatfi ?
ri.ACK OI- niKIM, OR Ki:M(.\\I, I DXIK.,;- P.iiuai. .,1 kj:m()\ai
'm.< VV
^^^
1
/â– >
INI
190 H
fAtMrcv>
N. B.
A-— <
-Fivery Item of information shoulil be carefully supplied. AGK should he stated BXACTLY. PHYSICIANS Khould
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for per-
sons dyinft away from home should be j^iven in every instance.
i !
>.
Vtk
m
t
I • «
I I
..f
'1
giT WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
'"""'"'"'""" ''•^'^■^^ ^'^^^"^'•^•" REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dill
(' Filed , LIa^vO/wV^
"XO
10()\
Beiistered Xo.
1101
Deputy Health Officer
DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco
Certificate of Scath
J? ^
JPLACE OF DEATH: — County of 0 CL/>\; O^CL/YVCo^bexCity of (JXX/>V J-^LXXA-uCAA^ac
A / IP DEATH OCCURsJTaWAY FROM
(
vcL
Cul St.;
Dist.; bet.
~ and
USUAL RESIDENCE give facts called for under "special information • \
IJ \ IF DEATH OCCUf»RED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
Cr'
ucLc'
â– )\.
. 1 i; < 'I' IMRTII
^HH
MmiuIiI
loO y..u
'Davi
Mm 11,^
I\i
i .E
♦t : ,
-i'-'.l.i;. MAkklJ-i).
H!I)n\VKI) OK l)l\( »RC ).; d
^^ â– ' â– â– il ill si).M);iti'ili)
'Stiitc or roiinli \ 1
I
• (
' â– ! r III
1 Alii Ik
'^'•" I \Tiii-k'
' â– mil I \
"^'MI'l'.X NAMl-
Ol M«iTm;K
I"Hllii-i,\ii.-
<>!• MoTIIKr'
"^i 'II- or C".miiti\'i
m
MEDICAL CERTIFICATE OF DEATH
^M.iutli) I fl);iv)
II^«;RI-:i:V CM^RTII-V. That I attcn.U-.I ,lc(x-ase,l from
IS up'i to IAaa.^ l*?i
that I last saw h j'v. mUnc oh vAaa^Q 1 1
(Vtar)
T90H
and that (k-atli oc^-iirred, on the- <latf statc-d ahovi-. at W'h^
^^ ^'-^r^^' ^^\IS '':,<> I- l)l-: ATII uas MS follows:
il9 XA^»^V^LtCt\.tU
(rvvo
lOJ
DC RAT I ON Yrars
C()\TRli:r'l"()RV
Mouths
Hays
Hon
IS
OX'WaX.
Ol/yx-cL
?
or RATION
Months
^'
OiCll
•ATlONigV?
(SIGNED) Uj/Vv\;Mri/X,Cu^^vrLcA^
Pays
I lours
M.D.
.vx:^ l"i i.)oH (
Xddrfss) vaX^, X Lo (/l:^-^^^.t
iTION only for Hiftpitdls, Inslifiitlons, Irdnsients,
Kfsidnf in Sdii /'nun;.,;, 'X% )',■,,•
1/-./////.
/',/â–
1 ■1. ^vl V !.','•• "i.V"'-'* '''''^^''NAI, PAkl-UTI.ARS A k l'. Tkll-: To T ! M :
'â– '>i <)i. ^1^ KNOW! i.;i)(;i.: AM) iu;mi:f
c.a'tciZjL,
SPECllAL INFORMAT
or Rt'rent Rt'siiltnfs, jnd persons dyinij dw.iv from home.
Usudl Residence k)05 ^JJ^^KX^<LLA^a^ jt PLirp of Deatfi? l^^
When was disease rontrac ted,
If not af plare of death ?
â– ]
Oavs
I'l.ACi-: oi' itrkiAi, Ok ki;Mo\\i,
\iMm
M XI'J-; 11! i'.i in.\i. .11 k I'lMoVAl,
ll
— ''
T90H
I. very item <.V inlformiition should b.- cnrofully siippMuMl. Ad'li Khould ho Htiiteil riX^CTLY. PHYSICIANS Mhoulil
stntc CADSn or DLA TH In pliiin terms, thnt it m:iy he pr««M>erly cIoHsilfied. The "SpecinI In^'ormiili.m" for par-
xons dyJn^ away from homo Hhould be ftivcn In every InHtnnce.
H«
m
1
V
1
I' *
i'\
*
f
1 1
â– '
.1
I
I
i^MI
.1 / .
;c
^1 ,.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
M..=,nl.,t Hcaitir I- NO i^-^^^iit^y^n RCFCR TO BACK OF CERTIFICATC FOR INSTRUCTIONS
I)((fe Filed,
ao
190^
Re^istej^ed J^o,
Deputv Health OfTicer
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of 2)eatb
( Xa. S. StanDar& )
J? ^
J?
^
PLACE OF DEATH: — County of C'/CLo^-O Axu^vov^c^City of C'<X^ru 0 AxXyv^/eA^si^cx)
Ncisaq
cLoyx^
(J/OAjL LI
St
.: .1
Dist.;bct. â– jXX)\.XJL
and d/OCr'U
/ IF OtATH OCCURS AWAY FROM USUAL R E S I DE NC E Gl VE FACTS CALLED FOR UNDER "•RECIAL INFORMATION" \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
si:.\
PERSONAL AND STATISTICAL PARTICULARS
rjp A I COLOR'
I'ATl-; »)!■lUKTM
U CTL^V
yy
,\
I
(\^{)iith)
A»'.K
0 i 1V,;;>
(Day)
Mnnl/l^
(Vear)
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATM
,1.1..
(Day)
(Month) j'
(Year)
Q
Days
>>IN<.I,K. MAKKIHD.
WIDnWKD OR HIVOKCKr)
'Wiitiin mKJal (]«-si>f nation)
151 k Til PI. AC K
'Statf or Country)
N'ANfK OK
\xx.<Lc!u
HIRTHPI.ACK
or lATHKR
fSlatf or Country)
^^AII)K^â– namk
OF -MOTHKR
HIRTHPf.ACK
oi- mothf:r
'^tat.- or Country)
OU'
kXj^
I Ifl'RICHV C1':RTIFV, That I attended deceased from
— to
I90
tliat I last saw h — alive
on
"190"
190
an<l that death occurred, on the date stated above, at ^ 3C
^Lm. The CAUSE OF DlvATH was as follows:
DTRATION Years
CONTRIBUTORY
Months
Days
/Jours
OCCtTPATlON
fff'^idrd in Suv /'i iini isrti
-o^/yxcL
DURATION ^ Years
Mouths
,1.(E,li).iJL
Pays
( Signed )..Lc-'uy>v£/v» O.VD, LU. AjLl<X'>vd.
Llc^A^g. i^ TQoH (Ad.lress) WurvvfA^ '
SPEci^AL INFORMATION only for Hospitals. Institutlo^sV Transients,
or Recent Residents, and persons dying away from home.
^
Hours
M.D.
Former or
Isual Residence
How lonij at
Plareof Death? Days
) \ a I
M.;,fli^
/)n\:
When was disease contracted,
If not at place of death?
"^"iU^vI't nv^*T.^T-^''* PHRSONAI. PA RTKT l,A Rs A K F TRI F To THH
UhST OF MV-KNOWIJvDCK AM) MFI.IFF
lliifi
orniant
(Arid
ress
ri.ACE OF BURIAI, OR RKMoVAI. ( DATIi^of Ml hjai. or REMOVAI,
XO 190H
undf:rtakkr
(Address .
JaD oXcililcl V \,Q
• • Every item of information ahouid be carefully supplied. AGE sliould be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information*' fsr psi*-
«on« dyinft away from home should be ftiven in every instance.
' I
ir
t
M
« 1
n]
t'i'
Iff
fii
i
—Wi"iW
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
». -. ) . 1
l-,ot*W 1? V*% It -fr.tf-iS^y. H.Vrl' <«
"Er ER TO BACK OFCERiiriCAit. rOn jiSiai HUCTioNS
/)a/r lull' (I, Hv^^/Qa^^^ 5,0 /.V6''-l
Iie^istercd JSI^o.
1J03
0<-A^
>'v...
Deputy Health Of.lcer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
i *a. S. StanDarO j
J? (3^ J
(^
PLACE OF DEATH: — County ofOCLO^ JAXLoox^UL'CoCity of C/Olav 0
CLAV JAXXA-XXtv^-C^O
No. SO^N
X''V\JL<L(7
T^jQi}
(IF DtATH
IF DEA
St,; 0 Dist,;bet. H I lxX^^ru^<La
OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER
and
SPECIAL INFORMATIO
ATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER
lU
" )
^\J
FULL NAME
^XAJ-OW; K)XKXX.'
â– ,\
PERSONAL AND STATISTICAL PARTICULARS
C<iI,<»K
LcJuu
.UJl
• '1 III kill
%s-i
MEDICAL CERTIFICATE OF DEATH
i»\ri". oi' DiiATu r\
(Day)
(Month I \
I M'Mllll
5-3
iDav
1 A. ;////>
\ I'.'iM
/ >,; I .
-^iN'.i.K. MARun:i)
"" '\Vi;i) OR DIVoKiKI)
ill MK-irtl (l\-sii.'natinii)
NAM!' (»!•
I- ATI 11-; K
fHRiiin.ArK
<>'â– i-Arin-.R
I State or Co'inti v)
MMI)}:\ XA Mi-
ni- M(»'i-iii-:r
(Year)
1 ni'RIvr.V ClvRTlI-V, That I atteii<k'.l deceased from
U\(yv 9.^ x^o'h t.) VTUv- a& Kp^
0%^ 'Xl
that I last saw li-0">>v alive nti
T90
and that death oreiirre<l, on the date stated aliove, at I ^.
-^I. The CAISI-; ()]•• l)l-;ATn was as follows:
a
A^^^VC/VVvX
A_.0
\y
<L
5)
h
%
1)1 RAT ION )\ays
CONTRIIU'TORV
Moulhs
Dm
'.V
/fours
l\r-idr(J III S',!,! /'i 111, : rn |0 )'.,ii^
"IK rni'i.Aci.-
OF MoTHHr'
(Stall or Coumr\-)
DC RAT ION
(Signed )
)'.j/;-.v
a'?^
Months
Pays
\ \ U)0
(•â–
c%JUrvvOL>>-cL
\(1(iress)VJ^^0LLcXyYu MD.
Hours
M.D.
Special Information nnly for llospitdls, Institulions, transients,
or Rercnt Residents, and persons dyin'j .may tro;n home.
y.'i'ih-
/Kn,
Ml. \linvK STATl-:i) I'KKsONM, 1' \ KTIiT I.A KS ARI-; TRIl-: To Till-:
I'l'.si «)i \j^v KN.)\\i,};i).-,i.; AND iu-:iji-:i--
(iiif,.
'inrint
\■M^■^« T b i
It
Former or
Usual Residence
When was disease rontraffed,
If not at plate of death ?
Kow lont] at
Plare of Death ?
ri<At:K OI-" lU'KiAi, OR ki-;m(ivai.
;iAU OK K 1-,
rxDi;
KTAKKR NL-\j. L/ \,yO''W/y\^(y\)
(Ad.livss 1(d^ Vi fVv^^^ ""
B. F.very item of in?ormnt!on should be cnrefully supplied. AGR should be stated EXACTLY. PHYSIC! \INS should
stnte CAUSE OF DEATH in pinin terms, that it may be properly classified. The "Special Information" for per-
«'>n8 dyin]^ awny from home should be j^iven In every instance.
\w%,
f
if
y
i
m
\
*;
I
.i^
h •
f
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
u,.„.,l ..I II. lit h 1" Vn 15. ■?'? :3->'5.«; !!X:I' Cn
/)ff/(' Filed ,
'XO
100^
llcgisfercd J\'*o.
1104
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Cevtiticate of 2)catb
( 11. 5. 5tanC>arC» j
PLACE OF DEATH: — County of UTVaX/vOj L{y^Lo. City of
No.
St.;
Dist.; bet.
and
/' IF OtATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
v. IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
a
y\/y\AJb
PERSONAL AND STATISTICAL PARTICULARS
JjLa-
\. ol iUUTlI
\/^a-\iXO^.
lEDICAL CERTIFICATE OF DEATH
DATE OF DKATH
Mciitli)
111 5V.M.
(I):ivl
Minilli>
'Year)
l\l\s
V.
Ab TQo'\
(Day) (Year)
I ni:Ri:i5V Ci:RTn-V, That I attended deceased front
to ..—
that I last saw h :^ — — alive on
1 90
190
'-l^â– 1,1" MAkKii;!),
u idmw j.:i) OK div()K(i:d
M.it( or I'liniiti \1
XAM1-: 01
fa'iiii:k
i''ii< riii'i.ArF
^1\!1)1;n NAM)-
"1 MnTm:k
ink rm'i.Acj"
<>i' M<»iHi:k
fStaU' (ii rouiiti \
• ' i I'AriON
f\''>!(ifil In Stui I'l an, i^r,->
\yQJ\J\^JLA^
<i^<i.CrV^^-^0
ami that death occurred, oil the date stated ahove, at
■^L The CATSr; ()!• I)i;.\i"!l Nvas as follows
{\j
nr RAT ION Yi-ar^i
CONTRIIMTOUV
Months
Days
Hours
I ) ( ■R A T !« ) N
)'i'ars
^fo)llhs
Pays
\\
«<
Hours
(Signed) b . ^^3) h>xxx:»/cWv-u' m.d
KAJ^^n rl i()oA (Address;) M f LOAA^^^^^ Louv
SPEdlAL Information onU tor Hospltdls, Insfitirflons, Transients,
or Recent Residents, dnd persons dviiiij avvd) fron home.
) V<; 1
M.OltiK
Ihiv.^
' '"iM^'^r*^ '■• '^■'''^■|'>"" I'KksoN Ai, i'\kTicr!,\ks Aki-; TkiH T.) riii-;
'•i-.^roi- Mv K.\(i\\i,i;i)c,H AN!) i!i:i,ii;i-
Former or
Usual Residence
When was disease contracted.
If not at place of death ?
How long at
Place of Death ?
Days
' X'l.lif^-^
I'j.ACi-: 111- nikiAi. ok ki;Mi)\ Ai,
rxniikTAK i:k Ow
(Address
l)Al"}:.o; ill KiAi. 01 kl-;M<»\\i^
S^t
IN. B. F.very item of informiition hHouIcI be cnrefiilly supplic<l. Ad'K shoiilcl be stnted liVACTLY. PJIYvSICI ANS Hhourd
stnte CAUSE Ol' DEATH in pinin terms, thnt it m:iy be properly classified. The "Special Int'ormiition" for per-
sons dy!n^ awny from home should be 6<ven in e\cvy instance.
•
I
♦.1
i '.
•111.
rt \\
'-H
:■«;..
k
'4
'.?
f; I
f,
.«», j
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I 1 ..f il*.«Uh-^I?Xn. ic t"-1^^»!^c H&. r Co
RPPTR TO RArK nc rPDTirirATr rno iMQTsiir-rirkN«
Xo
IfJO'i
llegLstcrod ^7;.
11 05
Deputy Health Officer
till
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
PLACE OF DEATH: — County ofLtm.
Certificate of "S)eatb
( 'Q, 5. Stan^arD )
JJuOu L^-ClLc; City of
No.
St.;
"Dist.; bet.
and
(IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME ^
'AyCOLhj Wv^/>v<Li.
PERSONAL AND STATISTICAL PARTICULARS
i>A 1 1: < »i- iMK rn
ljJ|\jt'
I Ml. n't lit
^ I
i )V„-
^
(Drivi
M-niH,
\ rai '
l\l\
•''VVK OK DIVOK* KI)
â– I'ial ill 'ii^';!!;!!!')!!)
HFRTnri. v'l:
c^'
NAM I', nl-
iA'nii;R
HiK riii'i.ArK
'>!• lATHl-k
'^tatc or Comiti \ t
s NAMH
j^V'^^^A^O.'
'>ayCrvA^nv
MEDICAL CERTIFICATE OF DEATH
DA Tl-; < »l 1)1. A III \\
m<>nih) (Day) (Yrar)
I HI':RI;15V C1:RT1FV, 'J'liat r attended deeoased from
— to
190 —
thai I last SMW h ": alive on
T90
190
ami that death occurred, on tlu- datt- stated above, at
— :\L The CAT SI-; ()!■DI-.ATII was as follows
i
m
t t
r.lKTIITM.ACK
')1- M'llMlJ'K
' '' > ir XTloN
M
'I
I *
DlKA'llON
CONTRIIUTOUV
}'euir.
Mouths
Days
J/Ollf s
/>''■■',/,■•,/ /// ,S',,')> / !,;n. -in
) 'r,l I
!/.•/,•///-
/h!
1)1 RAT ION )'r<!rs
(SIGNED )
a
/
.1/0// //r
r\
/hivs
to
I lours
M.D.
{'
U^q 'â– ^' KjoH (Addnss) Cj<X>v C)AX>^"yA.CAAt:L<A..at
Special information onlv for Hospitals, Instifufions, Transients,
or Rctenl R<'M(Jfnts, and persons dyinj away from fiome.
former or
Usual Residence
When was disease rontrarfed.
It not at plaf e of deatti ?
lioH long at
Plare of Deati! :
Days
1 UK \Mi)VK STATl'D 1'KRmiN AI, I'A Rl' IT T I.A RS ART! IRl)-; r< » \'\\V.
iiK>i oi* MY K^-o\\ij;n<-,i.; and hi:mi:i"
' \(l<lr»-ss
3AC1-: OI' luRiAi, OR ri:mo\ai
190 \
INDl-.RTAKHR
f
DA Tl', 'i! ill ui.\i. .1 R i:M» i\- \i.
N. «.
-hvery Item t)f inlformjition shouhl b.- carefully supplied. AGB «lioul(l he stated F.XACTLY. PMYSICrA'NS Hhould
state CAUSF: OP DFATH in plain terms, that it may be properly clossiified. The "Special Informutian" for per-
sons dyin^ away from home should be jlivcn in every instance.
%.
I
1 j ^
m
fa *
\
I
; M^
til
I
ili
«
!i
1'^
•»>
^p
um
I
(i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
. . .. t. tJ V
rjc-r-c-o •rr\ o a /* u <^ c /^ c ta-r i ri ^ at r rrMS t w e-rcs 1 1 ^ti<^ m «»
/;^//r n /('(/,
'ko
//y^n
Jiro'i,sf('/'ed J\^o,
11 06
Deputy M-,ith Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of Bcatb
( n. 5. 5tan^ar^ )
PLACE OF DEATH: — County
No.
b^d
Crvc-
/OL'V/K
St; S Dist.;bet. wJ/UXmywouvu and U)/U.t/Ou wl'
(ir DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION • \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
.irCL/ox/^'Yo.' Jlx
â– i \
PERSONAL AND STATISTICAL PARTICULARS
C«)I,t»K "N f\
h
'I i; I Kill
iXA^f^
OJ^J
Month'
bS
)V,,M
H
t I):ivl
.1 A ->////-
1^.
-^iM.l.lv. M.\KI<li:i>.
ni ^oi-ial ilt-i;'ti:itiMn)
I'.iR riipi.xiM-:
' M:itc or (.'oiiiitryl
lATll I'K
^cJ^^cj-^^aMxL
>VCi
mKTllI'l,.\i-H
OI" ••.\riii-;K
(SIrite- or Coiintrv^
maiu!.;n namf.
"! m<)Tiii:k
inu THI'I.Al'K
"K MOTIIHK
(Slatv or roiniti v)
MEDICAL CERTIFICATE OF DEATH
DATK Ol- I>i:\TII
n
'MmiiHii fC
(W-ar)
I ili;ki:r.V CI.RTII'V, Tlial I atu-n.Ud <lcH\a^o<l from
LLcv/Q n 190H t.) IAx/wk:! R i,,oH
lli;i1 I last saw h -^>' alive nil vXva^CL \'^\ l()0 'i
iiid lliat iKalli Dccuircd, on the ilak- staU-il ahove, at
~ M. 'flu- CWrSI'! OF I)i:.\'ni was as follows:
OiT
^""^%,
I )r RAT ION )V(7/-.v 1 M 0)1 tin
CONTRIIUTORV
I ) I 1< A T I O N Ai'' ''â– ^" ^ ''^" '' ^^^^
(Signed) VA-J- dsX^n-voX-cL
Ihxv
Hours
Pars
LLcv
uJklLx^
I lours
M.D.
Special Information '>'»'> '"r iiospiidis, insiifntions, fransicnts,
or Recent Residents, dnd persons d>ini| .iw.iv from liofne.
■I \l!o\|.; >T \ ri'l) I'KWSox \i. 1' AK|-nri,AI<S AKl! '1"I<I )•; To I'll I",
'•' ^T 01 \\\ KNMUij;i)(;i.: AM) in;i.ii:i-
'Itlf-lMllMllt
Former or
(Jsiidl Residence
When was disease contracted,
II not at place of death?
lloM lon(| at
Place ot Death?
Days
I'LAn-: (»l- HIKIAI, OK K l.M< '\ W.
I) \ii: ..:" !;■iM \i. 01 K I'.Mt »\ \i,
CLa-v>ol XX 190 H
(Address
N. B. Hvcry itom of inV'ormit ion should h.- cJirefiilly supplied. \<;ri shr.;.hl he st.ite.l EXACTLY. PHVSICI VMS should
Htntc CMlSn OF DI:ATH in pliiin terms, thiit it may he properly clnssirictl. The "Special Infoniiiilion" for p«r-
sons dyint^ nway from home should be J^iven in every inst«nce.
â– V
I
'W
(>
It
''A
4
! >
>J
.'^ni
*
yv
<â– % ,
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
1 , 1 ; M' r .NO, : ^
■• ^ • ^-
icrcn t \j ciM^r\ v/r v^cniiri^'
/;////' Filed ,
^0
y-V6>H
J?rgi,sfrre(l »A7>.
1107
Deputy Health Officer
DEPARTMENT OF PUBLIC IIEALTH=City and County of San Francisco
Certificate of H)eatb
i on
PLACE OF DEATH: — County of Q/a>X) 0
N(
(IF Dt ATM OCCURS
IF DEATH OCCU
S AWAY
RREO I
\/(VYVeAa/CC City of^^CUVu vJ A<x/vu:.ocixto
St»; 5 Dist.; bet. 1 1 ^tJk; and 1 i Lrv)
FROM USUAL RESIDENCE give facts called for under "special information" \
N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
WJu
C( )I.( »K
y'X\Xjj
liiK 111
/
^^^
M..i!th»
b5 )/./,,
I):tv)
1 A. »////«
• Year)
/'„■1
<o rvryj LA.).
MEDICAL CERTIFICATE OF DEATH
I) AT}-; < ii- I
n
)i:atii r\
I Month" a
I Hi:ki;i5V CI:RTII-V, riiat I attc-iKkd (Icieast-.l from
'Drtyt IVtarl
â– -INC.I.l' MAKkn:i)
NVlii. >\Vi:i) ( )K I)l\(>Rr )• I)
!i ^'H-ial (li-iv iiat ion )
liikTin'i.AOi-;
Mate iir <*onntr\ '
\^dLtr\A>-'iX^-
HIRTMF'l.ArK
"i lATIIKK
' ' '' "I rountrv)
MAIDl.N NAMl-
<»!' M(»Tin;K
"IkTmM.ACK
<)1" M(»Tni-:K
(Statf or Conntt v)
lip to
that I last saw li alive on
and that (U-atli ocrnrred, on the date statfcl above-, at
M. TIr- CAISI-: Ol" I) I {AT 1 1 was as follows
O-^-^Mrv-w^^
-V^VwA-^ <i^\^-xKjL .
IX RAT ION
)'':(7rs
Mouths
Days
//ours
C'( )NTRir.rT()RV
TVCr-UJ^vO;
)'rais
M
M
occ
:cri'\T!()N fO , I
^^^ h'ru'd^'I in S,U! /'i nil, ■••,) 3^0 )'>tli
^r,n,fh<
/>,!
1)1" RATION
(SIGNED )
Months
/\us
a
z6\
Hours
M.D.
Special Information nnlv for Hospitals, Inslitunons, Transients,
or Recent Residents, cind persons dving d>vd\ IroTi home.
Former or
L'sudI Residence
Wfien was disea^p contracted,
If not at place of deatli ?
How lonq at
Pidi e of Dpdtti :
Oav^
1 H): A Ho VI.: STAli; 1) I'KKSONAl, I'A K T IT C I, A k s A K I : TRIK I'l i rill'.
HI'.ST OF MV KXOWIJ-DCK AM) IU:M):k
(liiffriiianl
lA^.A-1
I'l.At'l-: nl' urRIAI, MR Kl",M'i\\I.
daim; of I'.MMAi, or ri;m()\ai.
rNni:uTAKKK
^- ^- F.very item of in? .rmntion Hhoulcl be cnrefully HiipplieH. AUB hSojIiI be stntc-il HXACTLY. PHYSrCIANS Hhouid
Rtnto CMISr Of- nriATH in phiin terms, thnt it may be property classilficd. The "Siiecial InVormjition" for p«r-
^'^r^% dyinjt nwiiy from homo Nhoiild be feiven in every instance.
.E
1 i
I.
^. !
'Si
h.
lil
yf
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
■k tm ^» ^ ^ ^m ^ ^% J> ^ 1^ ^K rt ^% P« ^ ^w ■^1 1 ^ a ^P^ V w^^ ^a I At <*> ^^ ^ ■■^ ^w ■^ bi 0^
/^^/r AV/r^/, LL^AXJ/L^vXit; aO /'V6'H
cLx>-^-^V.A^
llegisfeted J\^o,
1108
Deputy Health ORIccr
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
%
v
PLACE OF DEATH: — County of^CU^^ 0 A^<X-yvCA^^c.< Qty of '<Xa^ vJ.\yay>Aya>o(i.C0
'No. ^Ib CjljLCnvCV St.; S Dist.;bet. V) CUrpl' and U-CuK
(IF DEATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UnAeR "SPECIAL INFORMATION" '\
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAIxloF STREET AND NUMBER. /
FULL NAME
^J
iV^r^-WCM
rwi
V<X/A-\'
PERSONAL AND STATISTICAL PARTICULARS
/
xc
III i; IK III
\'.1\
I I'll I
\
n
(D.MV)
1 A. >////>
> I ai
/',
MEDICAL CERTIFICATE OF DEATH
!» A 11. < il' Di: A TH
Dav)
L-
(Month)
/go :
(Vf;ir)
• '.i,»' MAKi<n:i)
'>"Ui-.i» OK i)i\()Kri: i>
-•"•ial (!< >-i'..>n.it imi )
I'.IR rHlM.ACl'".
'Statt ui Cinniti \'
M 1 1)1-
.\ I II 1. K
niRTin'i.ArK
-^' it' ur ('(niiitrv^
I I IxXAX^wAo;
VOyWj
I UliRl'P.V ti:RTll-V, That [ aUeiide.l dccoa'^cd fn.iii
Vt.-t '^^ 1900 to ^ c^' 'X't IC90 3
that I last saw h'- ' > ah've (Mi U t. v .I'v Kp 3
ami that doath ociurrcd, on the date sta1f(l al)o\-i', at
^ M. Tin- CAISI- Ol- Dl'.ATII was as follows:
DIR.X'riON I }','(US t M on I In Pays
coNTkir.rToRV
Hours
MAn)i:\ \\Mi-, ,
niRl'HIM.ACl',
<>1" MmTII1<:r
(Statf or C'oiimr\)
1^
^^^ ct'^^u/va-
"> ^ .
O. ( 11
)'(â– (/ /â– .sâ–
.lA';////^•
DIR.XTION
( Signed )Aa. J XiL<rvva.*v<:L
i:t
F lours
M.D.
c*.
i
Special information "nly for Hospitals, Institutions, transients,
or Rt'(ciit Rt'sldcnts, diid persons dyin;} .may lro;n home.
M.'ulh^
/).,
Former or
lsu.ll Residence
When was di^^easr (ontra( ted,
II not at plare of death ?
How lonq at
Place ol Death ?
Od/s
'lllf.iMn:iut
I in; \Ho\i.: st \ri:i> i-kkson \i, I'arihti.ars ari". rRii-: ro
lil-.sr ()|- MV KNv\\ l,).:i)C.H AM) lU'LIlIK
V 0 . Vi rLuJLoLAA^
Sib ^\Ju.yY^JO\, ^.t
in;
(\.Mrrv^«
IM^CH 01- IMRLVh OK R i; M( »\'.\ I.
CrVu- v-V^-^ «i
i)\i'i;..: HiKiAi. oi ki:m(i\-.vl
S,
N I ) !•; R T A K !• R nI f\^ 0 odlcLtyvv M H? VO.VjLahXuN. 0
.\.l<lrc«*s ini \l rUA^>unv 3l
iil
AJ2J/YV
N. K. hvery item olf mformntlon should be cnrct'ully supplied. .\0K s!i!)iil<l be stated liXACTLY. PHYSICIANS Hhoiiid
Htntc CAlJSr. OF DKATH in pinin terms, thnt it nmy be properly classilfied. The "Speciiil Im'onniiti on" V'or par-
sons dyin4 iiwny from home should be feiven in o\ery instnnce.
^
^
^
C.
I
•4
•fi
ii
â– 'p
f 4
' «*J
^'1
\
(i'i
{ 'i4
m
life
,..:^%..\
â– %'^^wm^^'
(â– '
Ml
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Ui);il>I "I MCiUIti r ><) IS
r.i?5a?%^
trE-K *ipi-\ B*/«w r%ff r«rD*ricir'ATr vnn IN^TDUr.TinNil
• vito* ^>V t
Dft/r Filled ,
4
-Xft 100^
Deputy HcGith OfHcer
Registered JVo.
1109
DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( xa. S. Stan^ar^ )
J 0?) 4 ^
PLACE OF DEATH: — County ofO/CL/Yv OA^O^xcuiicCity of 0/O^^ru 0 Axxyw<icA.<:.c
N
o. [^^OkjJjL.
H St.; H Dist.; bet* H Uk* and 5 >
(IF DttlhH occo»»s *WAV rROM USUAL RESIDENCE Give r*CTs called roR under "srecial information- '\
IF DF*TM onfcURRCD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
Iv
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE 11
FULL NAME
si-;\
I) \ I K Ol ItlKTU
Ai.K
PERSONAL AND STATISTICAL PARTICULARS
I COI^OK
s-
I Month)
I O JVr/».v O
A
1%
iDjiy)
M.mlhs
^WJL
/ L^...l
(Year)
x\
DiJ ys
MN'.l.K. MARKIKI).
WIDOWKI) OK DIVoRfKl)
'NVritf in stM-ial <l«sij);natii>n)
UlkTHPI,\OK
' Statt or Ci)niitry '
NAMK Ol-
J'ATMKR
HlkTlll'I.ACK
Ol JAIUKR
(State or Country)
MA1I»i:n NAMK
"I MOTHHK
HIkTHI'UAOK
<»F MnTHKR
'Statf or Country)
MEDICAL CERTIFICATE OF L £ATH
DATK OF I) K AT 1 1 r\
LLuuo \%.
'\
(Month) A (Day) (Year)
I HI<:RI:P>V CIvRTIFY, That I attended deceased from
a
.0^X3L 1^ 190'
\%.
cu
190 H
iH to
tliat I last saw h -L >^ < alive on \-M,V^' iA up
andthat death occurred, on the «late stated above, at \0
\%
I) (RAT I ON i Years
CONTRllU'TORY
1 / I .."V 1 II V»tl> il
Months
Days
Hours
occr
_ djjijyx^yy^
Rf.sidfd ill Smi I'l ant i.^ro I Jl, )'riii s
Years j) font /is
NED)..U)., ^. 'Q\jL\>JL-^\Ji
DURATION
(SIG
/)avs
IH iqoM (Address) llO^
SPEd^AL INFORMATION only for Hospitals, Insmutlons, Transifnts,
or Recent Residents, and persons dying away from tiome.
M,»itln
Da vs
Tin: AHOVK STATKI) I'HKSONAI. I'AK riClKARS ARK TRl K To TH
J«KST OK MY KNOWl.KDCK AM) MIUJKK
K
'imant
(A.ld
rcss
iHip
'JKaJoJuu^.
Former or
Usual Residence
When was disease contracted,
If not at place of death?
Now long at
Place of Death?
Days
ri.ACH OK lURIAI. OR KKMoVAI, I DATKof Hcriat- or KKMOVAI.
(Address
ax% QfX^ Clllv^ w^ ii
A
N. B.— F.very Item of information .hould be cnrefully «uppliccl. AGE should be stated EXACTLY PHYSICIANS should
•tate CAUSE OF DEATH in plain terms, that it may be properly classified. The Special Information for pmr-
Rons dying away from home should be given in mx^r^f Instance.
1
^i;-i^
id
f
M I
*. 1
m
. s
f ♦"â– â–
7
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
rarT-c-Es ^r\ o n r^ u <% r r* r bt-i b-[ ^ A-r c pQp i ^j CTO ij r^y I ^ W 5
hnlc riird, Uo^^v^O/^^^ XO l'H)\
Ilrgislcred J\^().
1110
f
-•th O;
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( "U. 5. Stnn^ar^ )
ro
^0
PLACE OF DEATH: — County of L^CpKt/v^ W^to„ City of
VI I taAL<^
^JLA ^<Xl;
No.
(ir DtATH OCCURS AWAY FROM USUAL
IF DEATH OCCURRED IN A HOSPITAL
St.;
Dist.; bet.
Und
RESIDENCE GIVE fa
0=^ INSTITUTION GIVE
CTS CALLED FOR UNDER "SPECIAL INFORMATION" \
ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
(Vjd
D
.CL/^'ya^vaJL/'^
/CXv\L<r>"v-\i.
PERSONAL AND STATISTICAL PARTICULARS
^
C(>i.< »k
1) \ i'l-; < •! Ill-: III
M..iithl
n
) ,-,1,
i).
;i),iv
M.>tilln
Al^
\ I MI
Pd 1 .
wrt»(»\\).-i, ( »K i>i\'i iRi)': I)
' I ! 1 1 1 ^ i i- 1 1 ; 1 1 i 1 1 1 1 )
inkTm'i.Ari-:
'Stall, or CountiN
\ \ M I I li
»• A III l-.K
niR rnri.AOK
01 i"aiiii-;k
'State or r,,inili \
MAII)h:N NAMH
<»I MfiTin-K
iiik iinM.A'"]'",
<>i- Moriii-.k'
(Stale ,,r (.:(>unlrv
occrrATioN
v-CrV^Tv^
MEDICAL CERTIFICATE OF DEATH â–
DA 11-: nl- Dl.AllI , 7\
oUxo a 5
fMiinth) (Day) (Vt-ar^
I II I:K i:i',V C!:RTM'V, Tliat I attoiuU-il dccrascd from
— to
0
/QO
I (/I
til at I last saw li
alive on
T()0
\^)0
anil that death (uH'iirred, en the date' statt'd abow, at
M. The CAISI-; Ol- 1)1-; AT 1 1 wa-^ as follows
C
A.^<PW'
DC RAT ION )V(7/-.v
CONTRIHl'TORV
Mouths
/hiv^
//on
/ <
)'('(! rs .Vo>////s
DIRATION
(SIGNED )
/hry
I /0H)S
M.D.
SPEcIJAL Information «"'> >"r llospitdls, Insntiiftons, Iransienh,
or Rert-nl Rfsidenis, dnil jiftsons d\inj ,)h.)> Ifo.ii homr.
)â– ,•„â–
M '>in,<
ih>\-
%^X\
#
HI. MtoNl'. ST \ri: I) i'K KSONAI, |'\KliriI.AKS AK V. \\<V\-. T' » III l'.
iii-;sTni- Mv KNo\vi,i:nc.H AM) i{i-;mi:i-"
'â– inant
CTyOLm -'\Jt/v"vv.^^.^<xJC vVaJLA./A'^aaX'
• X'Mrcss
Formrr or
Usudl Rfsidt'iKf
When was discisp ronfrarted,
If not dt plate ol dealh ?
Hnv* lonq at
Pld< e of Deatli ?
f)ays
!) WV. ol" IIiKiAi. 01 K l{.M( »\AI,
OwV^cO QvO T90S
ri, VCl-, (H- Ml'KI.M, ''R ki:m<'\\i,
(AcMifSS.
.N. H. j;,,^.^y u^.,„ ^,^. ;„f,,^,„,,t;„„ should li.- cnrcfully Hupplied. AdK should be stnted f-WCTLY. PHYSICIANS should
state CAlJSr OF DrATH in pljiin tcri.m, thiit it m:iy be properly tinssified. The "Special Information" for per-
sons dyin£ away from home should be jiiven in every instance.
\
•1
*â– â– â–
lii
th
i
Pf
y-
\
â– â– ft
r t
>
iH!'*
p%
'tjutliili
•t 'i
:i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
t> I'n
RrFFR TO BACK OF CERTIFICATE FOR INSTRUCTIONS
!)((/(' tailed , IAa^v^Pla..^^^ XO
190 \
Registered J\^o,
11 10
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeath
( *U. 5. t5tan0ar^ )
L<pK1jvOu M> <^^t^O. City of ^1 I UxaX^^
PLACE OF DEATH: — County of
'Axa
Na
St.;
Dist.; bet.
Und
/ ir DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION • \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
0
CJ
.<X'^'>^>.^'
/CuvXL-cnA.^.'
' \
PERSONAL AND STATISTICAL PARTICULARS
.• . . i. « •!•■Hlklll
MEDICAL CERTIFICATE OF DEATH
DATK (>!â– I)i;\TlI
(Day) (Year)
>!oiith
x\
! ..u
iDnvi
M. in I In
/',/i.
^iM.i.i- MARK n-; I)
win* i\\ )• i» ( »k ni\< ii.', ).■I)
" ^' icial (Ic-i : â– â– : i
riii'i.Aci-:
'!â– Ill Conmi \
NAM) 1)1
iaiiii:r
IHR rill'l.ACK
*)|- I \iin-,K
'St.il( 1,1 I'nuilliv
"^1 \ii)1-:n namh
11) m(»thi;k
I'-lk riiiM,.\ii.;
fM- MoTIII-.k
(Stilt.- m roiiiiti \)
/\''^iilfil ill Sitii /'idihi'iii
[ 11 l-i'l i:i;\' C!{K'ri l-\', That I alttMidcil <U-(H-ase(l fn.iii
up to Icp
tlial I la-^t saw li : alive on I90
ami tlial iK-alh (nH-uricil, nil IIr- ilatt' stalt-il abovf, at
M. Tlu- CAlSIv Ol" l)i;.\ril was ;,s follows
DC RATION )((/;-.v J/ai/ZZ/s Dav'^ Hours;
CONTkllil TORY
I ) I ' R \ T H ) N ) '01 rs Moil His Pa vs Hon
/'V
H
^rr^j
(Signed) (d . ^ JjA.x\xx,<i
li^Q i^l i„oH fA.l.lrc-ss) Vl'l
M.D.
SPEcIJaL Information on'v for llospildK, institutions, Irdnsients,
or Rorenl Residents, and persons d)inj dH.iy from fiome.
Yr^n
M.-iifli^
I hi
I'm. \H')\i.: ST \|-i:i) im'. rsonai. i-xk ru i i \ks ari; ir i j-: r<> 111 1.
in-isT ni- MS K Now 1,1; I )(,}•: AM) n!:),ii:t-
(iiii
â– ' iinlll
CrV\J^<^ ->\jL/»^\^dA/"<x3C >AJL^^^^A.S t-
X.Mi.'Ss
Former or
UsurtI Residence
When was disease rontrarfed.
If not at plac e of death ?
How lonq at
I'idi e of Death ?
Days
I'l.Aci'; <»i III R lAi, I »K R i:mi '\AI,
M.l.RTAKl R fo oXaXj^ V
I) \ \'V: of Ml KIAI. i,t RJ'.Mi i\ Al,
\ 1 1 .
(A(l<lrc-'is
MH*.
Olv^
\A.<i.<.,<rv\ S}
N. U.
-Kvcry Ito.n o^' informntJon «h<.ul.l h. cnrcfully Kuppll.,1. \W. slv.uld be HtHtecl EXACTLY. PHYSICIANS Hh..ulcl
Htatc CAUSi: or DIIATH in ph.m torm^. th;»t it mM> ».o p.v.pcrly cloH«ineiI. The ' Spcc.»l ln»ornu.t...n »«r p-r-
Rons (lyin^ nwny from home nhoiild l»e ^iven in every inHtnnce.
X\
1
I
- 1
1: ♦
3i'
I
1 1
4
t II
ii'
I . I
k
^WT
l!?*t
III
^
fl
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
111 MM It- 1- >>• '-^
^'!Z!*>r. ,.o
/)((/(' Filed ,
ck-^r'^^AA^
10 7.vf;H
Deputy Health Officer
llo^Lslei'od J\^().
1111
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( "U. S. 5tnnC>arD )
A
^
^
PLACE OF DEATH: — County of a~>v J.VO^->\x:A.^ec City of vJ Cb-^v 0 A.CL/^xca,0. e c
o, HSt) vnAA.<i.k St.; 3s Dist.;bet. OUL<X\^'^^vu and dJxvlvcnAX
/ IF DEATH OCCURS AWAY FROM USUAL RESIDENCE GIVC FACTS CALLED FOR UNDER " S P Gfc I A L INFORMATION • \ I
/ I F DEATH 0(
l^ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREl^T AND NUMBER
1 (?Jl t
FULL NAME 'J .<X'^\y\^'ub M xXaxxA-vx'u
-â– )
PERSONAL AND STATISTICAL PARTICULARS
V ft I
JJt^OJ^
>\ IMKI'H
rl
M.ii>tli>
^1
),.,-.
il);iv>
1 /•■.////â–
/>â– !
> i.i" M\ki<n:i>
>ccL^''^< â–
•r t( 111 tit I y!
Mi: <»!â–
Ill IK
liiki'iii'i, xci-:
• lunl I \
!â– ! â– . N \ M i;
M' M II i: K
Of- MOTIM.U
\ 1 1< I.N
^J XAy\X/ij^\Xo^
4
V-' \-- 1^
MEDICAL CERTIFICATE OF DEATH
\ri-; oi- Di-.ATH r\
(Month) f
(Day) (Viari
I 11 i-R i'l'.N' Ci;U'ril'\', Tliat 1 ;ittc-ii.lc-.l (k-ct-ased fmiii
â– IiyO to Tc;0 â–
tliat 1 la^t saw h "" alive- on ~ ~ It/D "
aiiil tliat diatli ociiiri til, (M) the ilati- ^tati-'l al)o\-i', at
_ .M. Tlu- CM SI-; (»1 I)i:\'ill was as follows
O-v-^O'v
-f
^*'^/CXa,>^^0 L^-C
\jC\jL<x^-
s
^
' >(ArCtoXAX<X, -^ru dw
I )l RATION )V</rs
CONTRir.l'lORV
.lA^;////.v
/Kn s
//<;//
; .s
D! R.\'ri<>\
)'i iirs
.?/,';////.'
fSlG
;0
/hiys Hours
\XN M.D.
â– VQ I't TC)0'\
^
(A(Mr»-sv) L^r\xrv\JiA^ ^i >
SPECIAL Information f*"'^ '"r Hospitnls, InslilulifOls, Irdnsients,
or Rerent Residents, and persons dving dv\,i> Iron home.
Rf:.ii
•■t'tif<f ill Wnr /'i ti III im'i) O tS
1/, /^'//-
'111, \H( >\1.: ST \ 11 II l'KR>^()N" \1, r A Kl" UT 1. \K>^ \ K 1 '. I" R I }•:
ln:sT Ol- MV KNnWI.I-.DCK AND m.I.Il.l'
I » I' 111-:
'Inf,,-ii, ,nt
' X.Mlr^s
Former or
IsUfil Residence
When was disease (onfrarted,
if not at pla( e of death ?
How long .it
Place ol De.!fh ?
Oavs
ri.Ari-: <»i iti k i \i< «>i.-. ki;mm\\i.
%x G.Lv^.
I) \ 11-: of lit in M. "I K);M()\AI,
...vx:^ QsL
TOO 4
I ni>i-ki\ki;k O's/CX^'^
(A (Idlest to
X'\ ^^
N. ».-
-livery Item o*" inf.rm.tion hHouI.I be c»rciuUy s..pplio<l. AlJJi .hoi.ld be stnteH F.Xi\CTLY. PHYSICIANS Hhonl.i
«t«te CAlJSr: or DHATH in pl«in terms, that it may be properly cluHHiHetl. The Spccu.1 In»orm.,tu,n »or p-r-
R'>ns dyin^ away ifrom home Khoulil be given in avory instance.
; ^1
i' '
'Hi
^•■*ii
' â– 1
i'i i[
i
1 i
V
u
l«k.
tig?^^
w
RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
';.'!ll
K 1 \ , , , -. I'- - 5.- • ^i- I Il\ i ' * 1 )
^^ V^ I Mm •
I hi lie Filed, \Aju^yOiA^\.j:ikj O^Ci
rjo'x
Rci^istrred Xo,
i\rz
r-'
^li
docr'^-^-^^
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of S)eath
( "CI. 5. Stnn^nl•^ )
J? %
(h
PLACE OF DEATH: — County ofC'aiv 0,^CV>\CUi^O0 City of^'CL/vv J XXXyTVCA.XiyCvo
No. O.^t^'-v/^ru flb (y^lAx^LcxX) St.; Dist.;bet.
/ IF DfATH OCCURsIaWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLFD "^O R_ U N
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME 1
and
-OR UNDER "special INFORMATION" \
NSTEAD OF STREET AND NUMBER. /
FULL NAME
AXUn^Mi VjX^^XXO/^/Ij
PERSONAL AND STATISTICAL PARTICULARS
a II, I 'K
X
â– <X.>
I'.IK I'll
, % k. 1
MmimIi
\«,i.;
Hi
)'f,i I
I):iv»
M.nilh
/'
iUKTHPI.AOK
VxXAX.ou:^
1 â– . i ' I K
nikTlMM.AiK
<p ' ^ â– Ui-'.K
'"'iimtrvt
â– â– â– i'ni:R
iiiK niiM.Afi-;
OI- Mo'I'llI-R
1 i- y
,.v,,„s (y^
XfY\JiJ\^
)\t'' uh'il III Si! II limii ' <â– ')
r,-,M .
0 1 A, .,///< - /â– â–
Till- \!{. )\I.: STATl.:ii I'KKsoNAI, I'AK riCII. \KS ARi: TKri" Ti > Till-
lil'ST OI- MY KNoWl.lIX'.K AM) lU". I, I l-.l"
(liif
•niirnu M \W\J^ \| fLO^VA^XV v)
' \'l(ln
N. B..
JtXXX.a.--yO
MEDICAL CERTIFICATE OF DEATH
<I)av) (Ycar^
IJI 1;R i;r.V C"i:U'riI-'\', 'I'liat I atUMuUMl (Iccfasc-d from
S I(;nH to LLl^\^ ICi U)oH.
that I last saw h'0>>\ alive oti Laaa^Q. i Kp H
ami that death niHMirrcil, nii Iht- datr ^tati-d ahovr, at "
vj M. The- CAT Si: <)I' l»i;.\'ril was as follows:
MryWXoJl NclLfrVUt bcJC\HA,Lv*v lojAc^rvv 4 .Jt^a\X
.V<1
MOU//IS
/hns
C 0 N'l" K 1 rd • '1' () K \' \J AAA/>"vA.>CrvA,^X>uM v<0^"vOliL41
I lours
./•ur^v
DlkXTloN Years Months /hiis Ilonr^
( SIGNED )
Cd, UjvXaxia-vX^
M.D.
Ll<^^<\. \\ ic,oM f AddrfS->) ^Xh U/C^t(Xvi:>
Special information »"'> ^^'f Huspitdls, In^titutians, Transients,
t
or Reient Residents, and persons d>ing dway fron tiome.
Former or
Usual Residence
When was disease rontrarN,
If not at plare ot death ?
r \ \ \ Hov^ long at
LOA'vvyxj LaX: Place of Death ?
Days
I'l.ACI'". <»l^ IMKIAI. t»R R1;Mo\ AI
[» \ ri-. o* r.iMi \: .1 RlCMnWM,
cl AX>JL^' — .V. »
(AcMr.ss ?>0 5^ \)OX<r»Al.CyU LLvkC
TOn'i
.<X«.*v
fiver,- „.„, of i„!„.T,„..lon ,h„„..l h, c,.re,-„M.v .upplu-.l. Acjr. s- 1,1 "-.'"•"'^'•^^^■''■r; , ';''.''''',i''^. ^'D^r-
»tnt. CMISE OP nnATH In „.„in ter,,.,. th,,. It .n.y 1.-- ,......cH, cl..-Hie<l. The 8,„c,„l In,..,-,,.,...,... for p.r-
sons clylnft nway from homo should be ji'iven in every instntice.
Ui
( 1
.4-
1 1
If
\ i
ni^
t
I »
ji ! M'
' I
it^^^wWPa ft
siM«%±
w
RITE PLAINLY WITH UNFADING INK
!1. ..ll!' 1- V... I
* "^^
;;\ ;■'■•
THIS IS A PERMANENT RECORD
..^.^ ^r^ /^r-riTiri/-^ A-rr cno I IM ^T R U P-TI O N S
r K^ w. t 1
'\ji^^^j^ Deputy
if)0'i
Jlesff.sfcrrd J\^o.
i i 13
,-^-A.AA^
»
» ^ - »
'"> r».
DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( XX. S. tr1tan^ar^ )
PLACE OF DEATH: -County of O^av O/vC^xcu^oCity ofOct^x. 0 K^<^^^^
No. ^oil
ll! ,a.l.LL^.•
St.; ^ Dist.;bet. MAXA^CJl;
and C3/C^ tl
)
^ /V^V-Vx^ V.^N- *. ,,eiiAi orcTnVNCE: nVE FACTS^CALLED for UNOTR "special INFORMATION ' ' N
( ■' r".»roc"uVpr;,;,"r„os"p"*c :» ?.^',tu" ';'";*"i name .nstc.o or st«..t .«» ».«».. ;
FULL NAME ^ A\^ny\.<XA
PERSONAL AND STATISTICAL PARTICULARS
i\^
J^'TVaJjI'
IK III
\j
M..iUht
1 ,„. s
n
l);iv)
.1 /.'////.'
t ">iai )
n
â– > â– â– â– â– I 1 ' . OK [H\'t tk>.' 1.1)
iiil <Ksi)J:ii;»ti"n)
"~' â– â– â– I â– >in!liv
111 i: R
mRTllI'I, MK
«»!■i-.\Tm:R
- Stiitf or Cninitry'
M Mill- \ N.Wll-:
"': MD-nil-.K
l'.!R rUl'I.ACH
occir \ri()N
! r
MEDICAL CERTIFICATE OF DEATH
(I)av)
i).\ri-; oi- 1)1 .AT II O
iMontli) /[
1 !li:Rl-:r.N Cl-.R'ril'W That I atlcmkil <lcccasc<l from
that I last saw h -^ .>- alive ..11 Ltu^ ri I90 H
:m,l that .loath o(-rurrc-.l, on tlic .1 itr stat^-.l above, at X- ^ ^
*s.Lm. I'hv CAISI-: Ol' DIA'I'II \va^ as foll.)\vs:
(ViMil
O^Tu
<X/>vcL
'cJk^^rtro
Rt'.^itlfi! in S,!ii / 1 1! Ill i't'ii [
\
'.:.â– '/,. X /
â– iiii' Miovi-: s'l" \Ti".i> ri<'R^(ixAi, I'AR rirri.AKs arI', tri i: r< > i'" i"
I'.l'^T Ol- MV KNOW 1,1: DC. H AND lU'.I.Il'.l-"
(Xc^-vfct
T
.<^
1)1" RATI ON )V(/r\
CONTRIiU'roKV
Moiilhs \X /^n.v /A'
itrs
nr RATION
.1
.]f,uiths
vile
/?<?!'
O.
(SIGNED ) .
M.D.
) 1
^
SPECf^L INFORMATION f>n!v litr llnspifals, Inslilufions, Irdnsients,
PECmL IN
ur Recent Residents, and persons dyinij away Iron ti(.me.
Former or
Isnal Residence
When was disease ronfrai ted,
II not at place of deatfi?
lioH loni| at
Place ot Oeatti ?
. Days
I'l ACi- 01 r.i Ki \i. <"•; ''^ i:m"\ '^1.
e
h^^>;L^,
DATlj^.l' \\\-v \i • Rl,M.t\ \1.
1 NDlR'i'AKl'.K
..e.et-
A^
vC^
(A<l(li(>^<
, 11 h» t te»l r.X4CTlY PHYSICIAN'^ Khouhl
N. B. F.very Item oV JnJormation shoiiUI he c.irct"ull> svippUed. A'JIi s v>uhl he s *i •..'.•, ,„i-„^,„„tion" for p«r-
8tntc CMJSt: or DI:ATH in pl;.!n terms, that it mM> ho properly cla«s.t.ed. 1 he »p
sons (lyinji iiwny from home shoiihl he jiiven in every iiistnnce.
1! 'â– â– ;i
!
; ♦
^i*f
lum
> I
m
^'
•
-. ^
RITE PLAINLY WITH UNFADING INK
W
J , .,.,ith-F xn. ' ^ ^^'^'::r^ ^^^^' *-*"
THIS IS A PERMANENT RECORD
REFER TO BACK OK CLHl imv^mi c r
,,_.^._.. .__ ^»km 1 Ki <>-^>r« I I /«^| /^ M Q
\jr\ ii^Nrfiiiv#v*>i»»
pif/c Filed , AXaaXiv-v^ '>.C)
//Vi^VH
Jlvilistered J\'*o>
1114
.C^-A.^LAx<5 cLiLA^
De
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Gcvtificatc of 2)catb
PLACE OF DEATH:-County ofOJ.OAV O^v^^^c^Cc City o^J'Cb^ J .^v^V^v^a^oc
FULL NAME
<Xr\
V
PERSONAL AND STATISTICAL PARTICULARS
V ( tl.MR
.UIJL.
1 I', I Kill
,^^t
\!. Ml h I
I '. \'
• ■'\ i:i) ( tK I)IV( »!•'.» l.l)
n social (l(sij.'nali'))i)
. 1 M â– I . \ 1 â– 1 : /?\
M.lli ol '.'mmiiU \' I \'
!• \i'iii:r
1'.IR rill'I. ACK
oi^ i-Aiin;K
lst;it< 111 rnunt rv
M\1!»1,N' NAMl
MIR in iM, An-:
<)!• MitTlII-'.K
'Stall .1 roiinti nI
M,,t,tlis
/',.•
C' OU'^^vu
MEDICAL CERTIFICATE OF DEATH
DAI'l-: «»1 lU'.Alll
d.
(Monlli) K
Davl
(V.-ar^
I lli;Ki;iiV C i.U ril-V, riial I aUou.K-.l .U-roased from
lL^-v-C '1 i(>oH to Ux.^Q 11 up\
tliat I la^t s;,wh.^ ... iilivon LL^v^Cl '. iQo'l
•ni.l til. it 'K-alh niM-urre.l. on tin- .latr staU-.l alx.vo. at
a
M. 'rill' CM SI'! Ol- I>i:A'11I was as follows
A/vCVA/-^-v.cO
.AVA^iv
\ri()N rc>
'\'f' n/rif HI S.nr / iiii/.: I'.t O V_. !'"i."'-
1/..-/'//-
/i,M
I Miovi-, sr \'n.:i> im':u<.<)\ \i. p \inicri, \ks a hi: ruri: I'l > ii! i'.
lM.;sr (»!•• MV KNOW I.IJX.H AM) IU-: 1,1 1!!''
(Inf..-,
'.'• ^'1 .»l I |-V.-»^F\* Ifi. !'<•■( -».'•' «>».■,
unit M iLxXVm t). Vj Jn^*wk-V
DTK AT ION )V,^/\ rJo>////s /^ns
CONTKIIHTOKV
//Oitf s
( SIGNED ) LO-^aa^M' l\ ^.aA,vUs.
/hivs
IL.,
,0
Hours
M.D.
Kl'i
SPECIAL INFORMATION o»lv l'>r I'
or Recent Residents, and persons dyini xm\) trom home
~~~~ iHtspitdls, Institutions. Transients,
When v^as disease fontr.irted,
11 not at plate ol death?
Hovt Innq at
Plate ot Death?
Days
iM,\ii'. "1. Ill Ki \j. « 'K ki.;m< "X ai.
DATi-: of 111 KI \i "1 ui;m<»\ai.
'^V
mo'l
iL,..,..Wc.<i<u,.^\4x.uv^.s.,
'Ad.lK'ss
llll
%\
^^<IA-<!'^V
-^,4 1
"""*"' . I t teil r.XACTLY. PHYSICIAN'^ hHoiiM
IS, W. livery Item olf JiWoriiirttlon shoiihl be ciiroVully Hupplic*!. A*. J. k i<>.' ' ^? J" [ ^ri,' "Snccinl InV'oriniiti >n" for p«r-
HtHte CAUSE OF DEATH In ph.Jn terms, thnt it rn^.y be properly cIi.hm.^.cU.
BOit* flyinft nwny from ht.mc Hhoiild be tiven in every in«t«nce.
11
I n :
\
"III
V J»'l
, \.
%
i
< < ^1
â– I*.
',â– '
r
\\y-\
.;!'?
• ■'I
lllHl
liiji
4 I
I
\ l-l
r
I:
7^fa*'
4^ J I ,^^. ^^_
8
. i
HI
Hov
WRITE PLAIN
LY WITH UNFADING INK — THI
S IS A PERMANENT RECORD
^'
REFER TO BACK OK L.fc.n i ir iv^/^ . w .
/)(//(' Filc^l .
10
rjo'i
Redjstci'pd J^'^O'
I i 15
DEPARTMENT^ FIBIIC HEALTH=City and County of San Francisco
PLACE OF DEATH: — County ofU/CX/W
Cevtiticatc ot IDcatb
I XX. S. StanJavC j . ^.^
Si' ^ A ^
3aa^ ivcc^vxc^ City of a<^^ jAO^vev^Co
k
No.
OaK^^-- St.; Dist.; bet.
and
'JXWYVCLA^ -- - ,,<;UAL RESIDENCE G.v
(
r rACTS CALLED FOR UNDER "SPECIAL INFORMA
O.VE -TS NAME .NSTtAD OF STREET AND N U ^, B
TION' \
ER. /
FULL NAME
sjrxjyxMj
(Xy >\^
PERSONAL AND STATISTICAL PARTICULARS
\
IK ni
All
MEDICAL CERTIFICATE OF DEATH
viv. oi- Di'.ATn r^
V^
Month'
)
â– l):i\ '
I/.'"///'
( Vr;il I
/*,
, HI-.Rl-l'.V C1:kTI1-V. That^^ attL-n-lc.l .Urc.isca fmn.
llw.ri las^ia^vllâ– A-^ alive on
^IM.l.l-. MAKKll-.n
\v\\u i\\TI> ( U< I)IV< >K'' l-'.!>
: i! ilc^i'^Miali'iii '
lUKTlUM.ArK
•
(^
„M that aoath .H-cM,rrc.l. nn the .lat. <ta1e,l above, at \^^-
M. The CAISP: OF 1)1;AT1I was as^ol lows:
-Ml 01
\iii i-:r
lUR run. \rK
or i" \rii i:k
St .!( .,1 r<iutitfy
M \ 1 1 i . \ M
III Mil! III-. R
I'.IRI'MlM.Ari-:
nl- Mol'lllvR
fStiiti â– )] Odniiti y'>
> -CvJ~^^
UCCl TAl ION
DTK A TION ^'"^
coNTKir.rrni
Monl/is
/hns
I lours
dVDCrAOk.
(SIGNED) VI I ^^ '
UAA^n \q 100 H (Aa.lrcss)
Moulin I^^^y^
^Q \H !(>(
:diAL IN
Hours
M.D.
Rf'uilfiJ III Sail /•■»,///-/>'•,» ' ^)V(r)
III. AUOVI*. STAT)-.n I'KK^ONAl. 1V\ K T U' T I A RS A K l- rRlK T« '
lli:ST Ol- .MY KNOWIJUX'K AN D nivljl-l'
III)'
'liif<.ni;itit
IX^yVWOw^VN'
OVd Ch^-KAXoJL
c^prdlAL INFORMATION on!, lor Hospitals, Institutions, l^ansients,
or Rerent Residents, and persons dyinq av.d> Iron, home.
(T) ^ f] Hfl\* lonq at
How lonq at .
Former or l K j \^^^x,- pjnre ol Oeatti? Vo 0 Days
Lisual Residenr VU tviAJ^y^ - ^
place
.'J^-\i
ruACK (.»•• nri<iAi. OR ri.movm.
(Xu W)-^i^
( \<l(1ri's,s
i,\i 1 .,; w KiAf. -.1 ri:mo\ai.
LLos^ ^v'3v T 90 H
>Cna/aAJ'u:ti
!N. B.
' , pv^CTLY PHYSICIANS Hhould
«tate CAUSE OF DEATH in plain terms, that .t may .^; P^^^j;'^
«on, dyinft away from home should be ^ivcn in every instance
ft
Vil
hi
'\i
I
I
[|!iri
1!
It*
ii, II
x<m
11
., r^,^
iii'
li
1 1
:il^
Te PLA.NLV W.TH UNrAD.NG ,NK-TH.S .S A PERMANENT RECORD
WRI
u,/r Filed , \sXx^J:^y^^^^ ^^
.- r.n-r.pirATF FOR INSTRUCTIONS
REFER TO BMV^fN v»r N^...»
100^
Registered J^'o-
11 16
ih
^ \ Deputy Health Officer
DEPARTMENTol^ PIBLIC HEALTH-City and County of San Francisco
Certificate of IDeatb
PLACE OF DEATH:-County ofCla^- a^xx^^a^r.. Gty of
No. ^t*^
a.
. , , ^ a Dist . bet. Lol'-k^^^^ ^"'^ LUyovv^^-t )
f^r,!} - 'i S H UL'WIL ^^' ^ UlSX.,tX\. 7„„ „^„1, •special INTORMATION- \
FULL NAME
.^^
PERSONAL AND STATISTICAL PARTICULARS
COI,OR
w
HI Kin
^'VU
io
' NlMiithl
55-
5 v.;/
^
I
(I):iVi
M.itilh^
9 '
MEDICAL CERTIFICATE OF DEATH
I'-l
(Year)
IS
/',/i.>
^i3x^
l- MAUUn-.l)
• 1 11. \'' »'
r 1 Mimti %â– '
NAM I- ol-
1-A rin:R
iMK riii'i. Avi-:
ni lAIHl-.K
' Si.itf (If Country*
M\nil-.N NXMl-./OPS
•tl MoTin-.R ^Ul'
^\xxvvoixL
jJLolv^^.^vw
(Month* f "'='^-^
I iii.:Ri:r.V CI-RTIFV, That I mIUmuK-I .UTrasd fnm,
TcpS to CWoi IH TcpH
,„athat.Wathoccnn-rea. onnu-.l.t.^t.tc.l ah^v.. at
- M The CAl-Sh: Oh' Dl.ATll uas as follows:
l,r RATION 5''''^''-^
CoNTRir.rToRV
/-N-v -O..-
Moni/is
Hour
vj OLaJOv.^vAJL
^t^ '^A
lUR rni'i.Ari-:
<)!•■MoflUvK
(Slate or ContiliA
flours
:crPATi<)NQ^ . 5
(SIGNED ) civ. V
CLvA. l^ TwoH ( . T â– ,
"spec AL iNFORMATlblTT^tor Hospitals. Instituhons. Transients,
orlere^^esfde'-nts and persons dying a.a> fro. home.
Tin: AUOVKSTATKI) rKR>^..NAl. l-AKTICr I \KS A K l". TKri. To
in-.srol- MV KNOWIJ'D'.H AM) HhUll'.l'
(Inf.Mniant \] |V^ ^J . ^ A jW/V>Jut
HI",
Former or
Usual Residence
W'tien was disease contracted,
II not at place of deatti?
How long at
Place of Deatfi
Days
ri.ACKOl: HIM<IAI. OK Kl-MoVAI.
-.1 T90S
LAa,-*^'
1
/v^^
,^_^_^_^ "^ . , rXACTlY. PMY.SICIANS should
statc CMJSH OP DEATH in ph.m terms, that .t m»> ^^^^^^^^
son« dylnft uwny ?rom home should be feiven in ever>
ll
»^
-f»q^i-:>
inf^^
^'H^'"
4r %
'^'">-.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Ilmr.Iorilcr.ll). \ s... ;â– *-^i^K HSif Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
f >,!/,' lu'lcil. LLv^QvVA^ XO HJO^
llcfii.sleii'd jVo.
111?
ck^^-\.iwA-^
Deputy Health OiTicer
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of Death
PLACE OF DEATH: — County of UAt^O; Oaxx/>'vCa^oc City of OxX/-v^ JAxX/w;^o<iyO.
N.]
kV\
t
UL^^(ry^j St,; 5^ Dist.;bet. \XXX\^ and 13,
r :r DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G . V E FACTS CALLED FOR UNDER "SPECAL INFORMATION- \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
od
MEDICAL CERTIFICATE OF DEATH
i» ATI-; « ti m; Ai'n
i< r
H
r\^\
» 1 \
I 3^ )â– â– :,.
w
l-T
> I MI
/),/
GL.
1°,
/9o\
(Year)
! MARK n:i)
lURTHpI. \C}-:
'Stair .)r Cminti v>
'v/Cuv>v.ot<;^-
\ \
I Ili:ki:i'.N- Ci;UTll'V, riiat I atk'n-U-.l .Icreased from
UcVxV.Oi l*^ i<;oS I,, LLwvQ it U)oH
tliat I la<t <a\v h <- v , .ilivx-on LLAwV.<V \% l< MD ' (
aijj that (Kalli omirred, on tlio date statc(l almvc at I
( I
'^^ M. The CAISi-; Ol- I)I-:a ril wa^ as follows:
CI
i. i K
v»f
i
•t»
m
-^
IHRTHn.ACH
MAII>i:\ \ \Mi
•»'■■MoriiiiR
•■■•> ' M i'i.At'K
OF MOTHKR
' ^'''iintix
^1 '"^^'ri)
JU\
^
aLC.^
I )r RATION )'rajs
CnN'I'kllM'lOR V
Months
nays
Ilonrs
DIR ATfON
( SIG
rriON )â– <</; s .\/\<>i//is
NED) UJ . Vl . ^i^.CAw^o^Jk.CL»•
/>r/r
M)/^
/'V
M.D.
AV>/,/,-,^ /„ V, „/•,,,„, /.,-,, I-V )•-■,?;
CML INI
SPECML Information "nly for llospitdls, ln^(ilulif)ns, frdnsunJs,
or RtTfnt Rtsiddils, dnd persons dvinq dWdv fron home.
1/../////,
/),.•
â– ' "1 ..n KNOW 1,1, Df.].; AM) lU'.I.Ii: I-
formrr or <y
Isiidl Residence I bb i
Whrn v*ds disedse (ontrdcted,
If not at pldfp of dPdth ?
d. How long at
t Pldre of Dpdtfi ?
f)dVS
liiiiit
.\<uir.-.s H?) LUULrunv IXv^
ri^AcI-; (»!• HTRIAI, (>K R1;M(i\\I, j KATi;!.; Ml KiAi, (., rj:m(»\ai.
/CL-a OL » ^ ^^ Lc
IQOH
.very Item of ifif>rmHtion shoiil.l he cjireV'ully supplied. AGR sho ild be stated HXACTLY. PHYSICIANS should
state CAUSIZ OP DHATH in plain terms, that it mny be properly cl«ssi>ied. The "Special Information" for per-
R'>n« dymft n%vay from home should be Jiiven in ever> instance.
5'
; i
I
if.
rIv'Jii
^at^
^wfi
ill
i
I
WRITE PLAINLY WITH UNF^'^i'M'^ "^•-
J5(i;ii'! it lli;iitli I-' N'ti. k f--' 3f>,>L;- |{,''vI'Co
THiS IS A PERMANENT RECORD
REFER TO BACK OP CERTinCATE TOR > Nc.tpm^^.^..c.
I'JO \
Registered J\''o,
11 18
DEPARTMENT OF PUBLIC HEALTH-City and County of San Prancfsco
Certificate of IDcatb
( "U. 5. 5tn^^nr^ )
PLACE OF DEATH = -County of dct^! \ .^.^-^^ city of ^Co^'^
C ir or*TH OCCURS AWAv rpoM USUAL REsTorNrr ^^^'^ ^^** "^^ ^X5^^rurUCU>^; and J *>V^
^^^â– ^.... > -Cl)
FULL NAME C^x\.
^
PERSONAL AND STATISTICAL PARTICULARS
L)
Ojyx)
iKTil
loi
MEDICAL CERTIFICATE OF DEATH
i> A Ti-: ()) i)i:.\Tii
rJ^
; I )M
fMoiUh)
w
">-'v' (Vcar)
I
> ni.:ui.:i!v ciiRTiKv, ri,,,, . m.c.k.,! ,i<...„,sc.,i f,„„
,^-1
1 1 1A<;/,'//
N
?:i I.'
^' XkK I 1.1,
â– -ii'iiiilioiil
"1. \rj.;
' 'illlltl VI
i /'
'»'■I- \ nri-i; '
lli.it I hist saw h .=.' alive- on LLv^O i'
^
i':
1 90
<XV>^AoLxi
Mn.1 that .Ictl, o,-.M.rrcMi. ,„■1 lu- date- statv.l ahcnv. at t^- IS"
U. M. TlH- CAISI.; (^' OHATil was as follows:
^'AllU^N NAM,. /T)
rin;k
F I
I )rK.\'r ION
^ Signed )
>''"''V Mini I lis Day
Hon
rs
iUi ,. ...
yxfrs Mnnlhs
/^/rs
1.^-vOL'
' I<(oS f
I lours
M.D.
C: ^\\
O ( I ]. »
!:<
.i
n „ ^^^^±::i^"- ^- '-•^a^,>.„. 1. „
'"" ^-^—v<^b^ '^0,^^x11.
or Rerenf Residents, .ind persons dving dHd> Iron home. 'r^nsients.
Former or
l)sii.il Residence
When wds disease rontrdffed,
II not ,i( pidfe ol dedfh ?
How lonq df
. fd« e ol Dedth ?
Days
\.M,...s 30^1
JI.ACKCF iirKM,,,,K ;y:M-VM I nvn.;,, „,,„, .., kkM.,V\,.
im)i:ki" \K j:u
CAdiltrs^'
190 *<
n
U''
(•'I
^i" r»^
"i/s: »
u
write: PLAINI V IA/itu I iMr-M f>«....^
!!..:m.! ..( II ^,'ih -1* No. !>:, â– ^^''^^^-
5:^--? W^V r
.a-xlXJ
X^
100 ^
X(hv.ov^ Jvji v>-M Deputy Health Officer
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
liegi.sh'icd ^Yo^
ill9
DEPARTMENT 01^ PUBLIC HEALTIWity and County »f San Francisco
Certificate of H)eatb
( 11. S. StnnOarC> i
PLACE OF DEATH:-Countv oi^^3^^,^,,,^,,^ „, i^;......^^
No. cLay>Aji dbcy-^douJLo.
St.;
Dist.; bet.
( .r DEATH OCcJrs AWAY FROM USUAL R F «? I nV M /- r ^-^^St.; bCt. " -——____ J _
FULL NAME iv^C^^ l), lO(mi>vJ[,-
- )
PERSONAL AND STATISTICAL PARTICULARS
III
M.Mlth '
.^
Iv
I go H
(Ve.-ir)
\i
> â– :i I I
I'-l
%
1,',,,
^I AK-klll)
l'(
Tit
tli.it [ last saw li ^A^-^ ;ilive on
'"""•n, s,„-,al .l..i,M.,,ti,,nl
'"^:- "I <'..niilrv"i
'•■\thi;k
f>i" i"\Tin-:i<'
niKTtipr.xrp
MEDICAL CERTIFICATE OF DEATH
i> \\\: < ii- ni: A III r-K
^Mo„7jy^ (Day)
:^mpHHV CHRTrrv, That I atten.k.l deceased fro„,
190 H to LUa^ iq, 1,^0^
iM that .Iralh occurred, (.,, the dale siate.l above, at S
^ ". 'n'^'CA,SK(),^ ni^ATH wasasfolWs:
IXRATIOX Qi^ r,viy-.v
C()N'rRn!('i()K\-
\\
Vonlln /)ays Jjonrs
d^.
OrRATlOX }V..;-.v
(Signed) C>-yv^'\vidb Uw^^t^vdl^
^^ r<)o'A (Addnss) 11<^5
ttsVwt^^ \
I fours
M.D.
^^^^fi^'^}'}^^ORU\tKT\OH only for Hospitals, Instirttions frdnslprifT
or Recent Residents, and persons dying anay fro;n fiome. ' "^''"''^"'^•
Former or [ ^
Usual Residence \JX.
k'vJ^Jj^JLi
)•,,'/ >
â– '////\ (o /J,/i
■I'll'' \,„,vr •" '"' "■"">' Vo /^'M>
Wlien was disease contracted, tA (
ej,
Days
,JUU
flse coniractert, -A
If not at place of death ? O Oyy\j \^\X ^^jj^^
Y^M or HIR.AL OK KKMOVA,. I CxTi.; .,, „ „,, .,, „ jT:;^;^!^
aaAv|iKJi Cxi I (^'-^-Mi iL
IQOM
«t«te G\l"ir^oy/np\'TH" *''''."''' ^'^ ^«''e'?"'«y supplied. AGE «hould be stated EXACTLY. PHYSICIANS «h«. ^A
I
'â– 'fimi^^is^-
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
^'°^'^^.
HoMnl'.ni.MlHi IV... ,.■*T:W^J^,^S:I•(^.
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
; .i
Ihllr I'ilcii, (J^A..V<W.^ X\ iUO\
\j^^\j.yu^ XloMj Deputy Health Officer
llegLslcrvd JVo.
1120
DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco
Certificate of H)eatb
! 11. t5. 5tnn^nr^ )
PLACE OF DEATH: — County of
a..K,aj
^
N<v ' /^ â– â– >.
CMl,
wx
City of M Loi-x-ou v.a„l
.<xv
St.;
Dist.; bet."
and
^r
t
(ir DEATH OCCU|RS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
1^'
FULL NAME
UIxoaJLu a. v£
PERSONAL AND STATISTICAL PARTICULARS
ri »i,i Ik
II
%
LL ,'kv.O-
â– J xJx
h
'MMnlhl
Ar,).;
^fiH*l
H:-'
I);i\
1 /.>/,'//
» ( ;i!'
/',â– '
!X
MEDICAL CERTIFICATE OF DEATH
i).\ri-: op Di.A 111
a.
ri)av)
(V.-iii)
' i,i:. M AKRIl.;!),
-iviiatiuii)
,» , >.
N\M1 ()]â–
FATIII-R
HIKT (!!'!, \(1.-
^V" I" A I llF.k
(State or Cduiitryi
MMDKX WMi
"'â– ^I'>'i'iii:k
'*"< iIlIM,ACl-'
OI' M'iTiihr'
(Stat. ; r ,,:,,,
•H:cri'ATiox
I lIlvUI'P.V n:i<Tll<V, 'I'liat I .tltciidr.! ilcccasi-d fn. in
1^^^ h^ to (Xca^Ol l^ icpH
lli.it I last saw h ..V>^^:tli\•c• on Llx^^/Q IH np'\
aii'l that (K-atli ocrurrcil, on tlu- <latc stated aliovx' at \D- A.5~
V M. Tlu- CAISI'. ()]■• I)i:.\'n! was hs follows:
Dr RAT ION )',a/s
f () N "J" u I r.r 'I'om'
M out In
Days
Hon
rs
1
(Signed) 0. uvj. O.U..^^
Months
PiU
'.V
a
M, 1 (^ i'
'^ (. T(,o'l (Ad.ln^O \i L<X-lvQj VO,('
fA
I hutrs
M.D.
AV ; ,',,/ ,,i S:nr /',
I (HI, nri>
5 ',•,/; .
yr..:,fl,.
/'„■!
' " II. M-r'yw'iT^ '"'•'" ''KU^ONAL rAKTUTI.AKs A K I". IR!-]-: T. . T1!K
'■'-^l <>!• MV K\. i\VI,!;i)C,H AM) lU-Ml-F
SPECIAL Information nnl\ for llospitdls, institutions. Transients,
or Recent Residents, and persons dying awa> fro.ii home.
Former or ~\ ^f Hov\ lonq at
Usual Residence 'J <Xnru O'Xa ^ ~ - pue of Death? o rv|/>.... Days
When was disease contracted,
If not at place of death ?
ri,ACi': ()!•■nrRiAi.oK ri;m(i\ai.
DAl'l'. of liiKlAi. or R1:M()\- \l,
a.
.-<.^wQ- A 1
I .ni>]:rtaki-;r vJ<XCA-i-v/C. LL/vvcOlAXoJr
1^1 QO\v^^c^ cS:l
T 90 ;
r\(l. lies';
N. B K
Kvery item of itiformntion should be cnrefully suppIi.Ml. AJJE sho ilil he stated H\ \CTLY. PHYSICIANS should
state CAUSE OF DEATH in pinin terms, that it may be properly classified. The "Special Informjilion" (for per-
son* dyin^ away from home should be feiven in every instance.
.1
i
^1
:i)!»i:
•.^A«
!A.^»!
i?tfK- WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
H,,.M.l .{ IK i!lh '!■Vn. i^ ■t>-f';'r»';X- wS^v Co
^^v<y-^cAt a I
I!JO\
Jieo^/.sfr/'prl jYo,
1121
Deputy H
Officer
DEPARTMENT 01^ PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
11. S. GtanC>ai^
m
PLACE OF DEATH: — County of C)/0^>v C/.VCL>\cuic^ City of O^u^^' J.'UX^v^
<w^C.<.
N
o"^ (ll:'Crv\>avd
St.;
Dist; bet. 1 1
and
I a)
\)
(IF DEATH OCCURS AWAY FROM USUAL R E S 1 D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
cLmaa^ \x)
xcNiyrvj
PERSONAL AND STATISTICAL PARTICULARS
Ci il.t »K
DA
.0.Vl,<^O-
MmIiIW'
t
(l):iv>
MEDICAL CERTIFICATE OF DEATH
1) \ri{ (>!â– i)i;.\Tii 1^
5vC
(D.'iv)
' VlMI
IH
)
II
/ 1 ,
\\ II
♦I
I'.iKTir,'!, x.i:
f-A riii;R
HIKI'IM'I \K.V
f>!' i-AlliKk'
'St.itf or 0..inilr\'
\"\M1
'oinitix-
V J XWVVOL/-YX^Jl_
(Month) ,\
I ni:Ri:i;\' Ci;RTn-'V. That I alU-iuUMl dcivascl fn.n
tliat 1 last ->a\v h X'Wv. alivt- oti LCvvol '^ C) iip'l
ami tliat dcatli ncrurrcd, on the ilalc- stati'd ahnvo, at I
(X M- 'I'll*-' CACSI-; Ol' I)i:.\'III was as follows:
DC RATION "i )Va;,v
CONTI^: IIM'IORN'
Mouths
Days
//on
t s
nr RAT ION
)'((irs
M.oitli>
/hrrs
V^V*/ >v
'X-'^-'ll'Miox
' â– Xj\y^^-'^0^-\
\.
1
SIG
NED) VjV(rlsJll\t) (MJ.UaK' n
^1 i.,o'-\ (Addn>.0 'k\^\ JbowMXvA 3<
'/// ^
M.D.
dlAL
SPECi'lAL Information «n!v (or HospltdK, Instilulions, Irdnsienls,
or Rcrenl Residents, dnd persons dyin;j d\*dy from home.
1 ' â– ///// >
"'prJi!.*^''.-^''^ ''"'•■'* '•»*■'< ^ON.M. r\UrHT!.\KS AKi; TKl J- T<> Till'
'"f'Mnant \J fVu) 0»v/Vn^Oo JUV<^'C
\-Mr..s X\^% do Ch^-V^CX
former or
Isufll Residence
When was disease rontriifted,
II not at plat e of death ?
Wm ionq at
PIdre of Death ?
Da>s
I'l.ACI-: <>I- lU RIM, UK KI;Mi'\
1,
i) AX'- "' 1" i-i^i "I '< iySU »\ AI,
N. R.
Kvery item of ijifopmation should he ciircfully suppIKmI. A(iB should be stnteil HXACTLY. PHYSICIANS should
«tate CAUSE OP DEATH in pliiin tcrm.H, that it muy be properly classified. The •\Spccial Inforniiition" for per-
son* dyin^ awny from home should be <>iven in every instance.
f
r 41
i ^
, i
« -
* *
t,
.V
w
I â–
U
!'!
11
|. \
• \
, -f^U*.
h
n
c
(
r
v!
''I
' J
i
)•
•:\
< *
Ui
i^ \
*l«fP^"
.«*•*.■•■■v^>^. -/^ â– '. â–
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Bor.r.l of 1 1. all hi- No. i<; t-?.;«';- *-^ iit^i' ^'•
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/)(//' AVAv/, vXL>wOyL^^AX Qvl
kaj^ 6uu\xa
J!JO'\
♦« p r-v
lloiULslci'ed A'^o,
ll2ii
DEPARTMENT OFPUBLIC HEALTH-^City and County of San Francisco
Certificate of iDeatb
( 11. j5. jr»tanOai^ >
No.
PLACE OF DEATH: — County ofCla^x- O.^CU^A.'a^^<Mj City of CJ^tX^^ 0 A^<Xav<^^^CO
'Ill lt,^,v.- St,; X Dist.; bet. W 0 a>vhjU^ and V.A^.V-^^
ir DEATH OCCURS A\Ntiy mOM USUAL RESIDENCE give facts called for under "special INFORMATION' \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
.U^AixXy
CU
,- ' s
AJ^'-V\, ^ v, V
^1
PERSONAL AND STATISTICAL PARTICULARS
: :k 111
J ^>
Dav)
A^.l
roo H
(Year)
at .
^ /
/>â–
""iN".!,!-:. MARK nil)
un>< '.^\^v\^ I >iv i)!\-( iKri:()
1' -it'iiat i'lii 1
IHIMIU'i.ACK
â– 1 o 1
i i IK
Ayv-(rvoL/d.
MEDICAL CERTIFICATE OF DEATH
i» A v\-. I M- i»i;A'rii r\
fMontli* /] (Day*
I lll';RI-;r.\ l i:R'ni"N", That f atk-mU-d .IcM-casd fn.iii
Y^M '^^- Kyo . to LLuM3. aO U)0 H
tliat r last saw h X^u alive on ^Vv^Q 'Xb up '
and that (K-atli i ic'ii ricd. mi thr ilatr staled al>M\-.,-, at I
\) M. 'i'liL- CMS!': OI" l)I-;.\ Til was as follows:
HIKTUIM.Ni I.-
I.I . V . I||.;^
''iiititrv
IM-.K
«>J- Mo'iiii.-r'
Id. dl
to
DC RAT ION - );^
^~
- M,uilln
Par
'S
(.' () N T R 1 1 '. r 'r < > U N' 0 XAJUx^^CAAX^tX>v \l AJLavv^wclv Iv. .
1 lours
t ! V
'"â– 'I I'A.Tlox
DTR-ATION )'<â– <>>â–
SIG
NED) VAA'AjUAJ. \tn
Mouths Pays
XO Tc)oH
Addrrsv.) OXclNA) JV/V^vQ V^bAd
Hours
M.D.
SPECFAL INFORIVIATION ftnlv for tjospi
or Recent Residents, and persons dyini) iiwav fro:n home.
)itdls, Institiifions, T
-4-
M->,!h:~
n.i\s
III \lii,\-K sT\ri:i) I'KKsOVAl. r.\Kl-UTF,\KS AKI'. TKri'. To \\\V.
former or
IsudI Residence
When was disease conlriifted,
If not <if pU e of death ?
How Innq at
PIdre of Death?
ransienfs,
Oavs
fli!f'>Mii:mt
(A.un.s iHHo U'oll "at
VXV
ri,.\ci'; (»i lURixuoK Ivi:mii\ \
:^\ U- ly. 3 . CvX/^-vvCLtyvM
1) \ i"i; â– â– : li' i.'i \i ..I ri:m()\- \i,
^''*^ 1004
CNDl'.K'IAK]: R
%
N. B. livery item of 1n?ormntJon should he cnrefully supplied. AGK should he stnted f.XACTLY. PHYSICIANS should
«tntc CAUSfl OF DHATH in plain terms, that it mny he properly classified. The "Special Informntion" for per-
sons dyiniJ nvvny from home should he ftiven in every instance.
id
4
t
.>si
J,
• 1
' I
>«- .
f I
I «
dUi
\\y\
M^sissi^^^s^
iL^M
1 'l, '^l'
'm
.n^' i
ifi'
t.
,.r
ij
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
liD.i;.
- Isl^'ar^tolUS:!' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
J? 0
7,Vf^n
llcgLstci'ed Xo,
jL\ ^.^<5
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 5)eatb
J? ^^ J? (^
PLACE OF DEATH: — County ofCJCL'^^ 0,tv<X/'>xc.c4.C(.City of C)/0-/-rv O AXlo-v^v^ -c <.
INo. I V \
J ^ '...J St.; 1
(ir DC^TH OCCURS AWAY FROM USUAL RESIDENCE Gl
IF bCATH OCCURRED IN A HOSPITAL OR INSTITUTION
Dist.; bet. 3^'Ax.J/\..trrCl)
and Ut<>-
IVF FACTS CALLED FOR U n'd E R "SPECIAL INFORMATION" \
GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
\Xtr>v )
FULL NAME
Al}
PERSONa-XL and STATISTICAL PARTICULARS
Cni.ok >
^ i!
:â– : \'\\
u
Month*
MEDICAL CERTIFICATE OF DEATH
<I);iy
Mi.ntlil
(Vi;ir»
M..ul/n
^
/',/!..
SIN.,I,H. M\KKIi:i)
:il (U'sijrnatioii)
ni:.-
N \M1 (II
'•atiii:r
'I : \
I 1
'ii;-: i 111'! ,. ..
IStatf lit- Cutititrvi
MAIIi) v WMj-
<M Mm III J. K
''â– "<i'in'r.ArK
"1 ^^■■^!^•K'
iiiintiv'
UJ
1 Hi:Ki:r.V Cl.RTirV, That r alUn.U'.I .Urease. l frmii
— • I(;0 ti ' ■'^-■~ H)0
that I las! ^:i\v h •■- -ali\iMiil " ~ lip'
ainj that lUath « ircurrt'il. <>ii thi- datr statt-d al)(t\\>, at '
M. Thf CWi Sl{ Ol' l)i: ATII was as follows:
d^rv^-^-^k
CV_Avd- ' J^ -C^->^<rVvKccciLX' Xv-crvvv
IXRA'I'ION }V<;;',^
C( >NTkir.r'r()RV
DTK AT ION _ )V(?/.v
Mouths
/hiys
Hours
(Signed ) L<r\^rk^i2A; o. vij.llj. cLuLcl/aax:)-
I^ay
/ /ours
M.D.
SPECiAL Information nnlv for Hospitdls, institutions, fransients.
or Recent Residents, and persons dvinq a\*av froni home.
^r,>>,ili- - rh^ I
»'»-.M OI- MV KNUWIJ.-.DCH AM) M1-:m1-:i-
fliifoniiant
Former or
Usual Residence
When was disease confr.irfed,
If not at place of deafli ?
ri.ACK ni- HTKiAi. OK i;i;mo\ai.
How long at
Place of Deaff) ?
Davs
DA'm; .)! Hi Ki.-vi, -.1 Ki:M(>\ \|,
T 90 "-l
F.very Item of information should be carefully supplied. AGB Rhoufd be stated RXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain term*, that it may be prc.perly classified. The "Special Information" for p.r-
"f^n* dyinj^ away from home should be ftiven in &\ery Instfince.
i?
< M
' If
'.fi
I I
» (
m
*W5(C!?.
m«mi
i lllil'-'
I Wi
I
ill
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
n.,;,,.!..! li...MI: IN" '^ ^•^';^-. it>.lT..
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I)
life Fih'd y KXx^Quy^^J^ X\
V)0'\
liCgisfcred J\^o.
1194
i
Deputy Health OfTlcer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Gcvtiticatc of IDcath
( tl. S. StanC>arC> )
J? (^ SI %
lo»
PLACE
OF DEATH: — County ofO/CLTu J.Vao^e\.<ie( City ofCJ/CL/Vu 0
A^Cu^vc^^Ai e,o
^' CL ^aa^LolX-a^vv. -^ ^ ,.
St.;
Dist.; bet.
(IF DEATH OCCURS *WAV FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
!i
4^
-U
|V/. t
MEDICAL CERTIFICATE OF DEATH
DA 11. (U ni'.ATn /">
Moiitli)
45
) ,.n
!I):i\ I
Mnillr-
/his
"il< 1 !l IM, AOl-:
(St;i1r <i\- rountrv*
N\M
X^^vKX^WM
\% n^o \
u
Dav^
(Vi-:ir)
I HJ':ki;i;\ i l, U'ril'\', riiat I attcii.K.l .Iccrasd In. Ill
tliat'T last saw li .ilixroii vvA^vcy. i v. jtp
aiii] tliat (Uatli < >tHMiiic'il, on tlu- daU- ^tatc-il ahovc, at ii. \0
M. '1'Ik' CAISI'; <)I- |)1-:.\T!I was a< follows:
\w CXAyCA^-W,^rv" WO^
OV itO v.v .'^^-cLLAxi
'V>uic>'T»
y
HiKrni'i.xcF
OI' I- \T!II-K '
(St;U<
^
' ; \
^'Ali.i:\ \AM).
OI- Mornj-.k
'VCr^^v^
â– 1 n , i 1 ',
4
i 1 o N
f^'f!(!r,f III S,i)i I I
Ux^^"n^vOw-KV'
, IB )v,.
I )r RAT ION )V<7r.? Moiith^i Pays J /ours
Dlk A'l'K )\. )'r •///•? Mouths, ^ Pars Hours
f SIGNED ) OAxAxVLcJk LU. oU tv^iwYo M.D.
%
SPEciAL Information '•"'> t'»r Hospitdls. Instilutions, rrSnsienls.
or Recent Residents, dnd persons dyinj .m.iv Iron fiome.
former or a.. ^ "M f J - "M i i I ""^ '""^ •^'
L'sudl Residenre^^O \^^\.O^Sa^ OClUUvvPUp oI Death?
Ddys
/<,^'. -
' "prJ','*^ '• '^■'■'^■'''•'■!> !•>• USONAI. P \ IM' IT I " I,A K > AKl- T!<I I' To TIN';
«l!if ,:„,,,
' ^<1llress
1
ru.
When was disedse ronfr.iffed,
If not at plafp of death?
QUfe
ri.ACl'; ( >1' 111 J^l \^l, oK K1,M(»\AI,
rM)i:RTAKi:i; Vx^^^xiU
>\I'Km! Ill imai, or K l'.M< i\AI,
0-Cv~x^'\
N. K. Kvcry item oV information hIioi.I.I be cnrefully Hiippliccl. AGK shoiil*! be stnte.l LXACTLY. PHYSICIANS hUouM
«tiitc CAlISn or nr:ATII in pUiin tcrmn. tfint it mji> he pr.M»er!y classified. The "Specii/T InformjHl.n" f..r p«p-
K^ns (lyin^ uway from home- should be Jii\en in every instnnce.
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nn:,nl..fll r'. rvn ,- t^^^;^^^^)l{S:l^CV,
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
J)
II I c I'^ilt'il , LLM^xyL/v-^^iX Q^l
rJO'X
llegisU'i'ed jYo,
\ i 25
ck^CrVCA^ ci
Deputy Health OfHcer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of S)eatb
( 11. S. Stan^arc> )
PLACE OF DEATH: — County of ULL<X->->^^cLo.; City of U/0^kX<X/-vvd.
No.
l'^'^
â– ,ti
A.-
St.;
Dist.; bet.
and
f IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECrAL INFORMATION ' ' \
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
oX^oc/l'l ooji^-y-K-^h..
PERSONAL AND STATISTICAL PARTICULARS
si:\
(â– ()I,( >R \
bjl.t
i< 111
M.,n:l>. J
\^^.
/
^ '' (.
IdH
/,///'
/),/
w iM.-' . .) (^^^ I,!Vt)|•^ i';i)
'^^ Hi:!] (li sij^Miiitiiiii)
III
-lis-)
N \M1- <)!
iatiii:k
liikrui'i \> }••
'^"' >'atiii.,r'
"^tatc .,r O.iimtrv)
LcuuvoocL
ol/>^^.
^Ou^rnjL^
MEDICAL CERTIFICATE OF DEATH
DATI-. Ol- Dl.ATH '~\
;M.mth> A I):iv» (Year)
I II i:i< i;i;V CliRTH'W 'I'b.il I atU-iKkMl dcci-asfd from
— — up to I()0
that I 1.1^1 ^i\v li .~ alivf on lip "
ami that tUath o(H-urro<l, on the dali' statt-d alxni-, at
M. The- CAT SI- ()!â– I ) I! AT 11 wa^^ as follows:
M\:!n \ NAM).-
<ii .Mo)-ni;K
inkTiii-i.Aci."
'>i' M()Thi.:k'
estate or Coujitrv^
'" ' ' i \rinx
Lw o.
I )r RATION }■<•(//•.? Mouths Pays Hours
CONTRird'ToRV
I ) r R A T K ) N ) V(?;\v Months Pays Hours
(SIGNED) ;'. . vfc.y l'UJvA./->^v.o., M.D.
VA>^C\, :.'. i()o'\ (Address) v^',0^<^X<X>\A Wt
SPECJiAL I NFORIVl ATION "nl\ lor Hospitdis, Institutions, Fransipnts,
or Recent Residents, dnd persons dvjni] dwdv Iro-o home.
''â– '':>lr,l ill Si:>' /'iinni i-,> '~~ )',â– ,; i
\J..n'l,-
/',' 1
""..,^'•1.'^ ''• '^■'■^■'■'■■'» I'KKSONAI, l'\R'rifri,\KS AKl' TUT I! To Tl
i.i'.sroi- Mv KN«.\vi,i:i)c,}.: wd hi-j.ii:i-
1 1:
Former or
L'sual Residence
When was disease ronfrarfed,
If not af place of death?
Hum loni) at
n,i.e ol Death?
Dd>s
I'l Vfl". nl' lUKIAI. OK UI;Mi >\ AI.
\J^Jii-^'^
I N 1 . 1 ; K T A K V. K U 0^^r^Xyy\JJ^ ^
TQO
A.^^.^^
^Xd.ll.-.'^ I'ivO'^
(Y)\v^
i/s-^
'.t
N. B.
r.very item of Information .houlcl be cnrefully supplied. AGE bHouIcI be «tnted EXACTLY PHYSICIANS should
«tnte CAUSr OF DEATH in pinin terms, that it may be properly cla«8ificd. The Special Information for p-r-
S'>n« dyinft away from home should be ftiven in every Instance.
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REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
190 \
llci^istered J\^o.
Jv^A,^v^ J^JLvKt Deputy Health OfTIcer
-5>
1 1 26
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of E)eath
[ 11. 5. Stnn^arC> )
No.L
PLACE OF DEATH; — County of 0 <X/yv J XCL/ixcxA ao City of OoLAX! OX/<X^xau^cc
X
yxM
CK-^vCt
St.;
Dlst.; bet.
"and
/ IF DEATH OCCURS *W*y FHOW USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION • \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
r( )I.i >K
/ lXXXI\_v cVC
!K III
(5^1
MiMltllt
as
(I):iv)
r
\^:-
iS
5~
1/ .;â– //
ll
^fV«.l.K. MARKIKI).
n-i:.. ,\\-i.i, , .w i)i\-()H(.-Ki)
<i'. '•ipii.'itioii)
I! IK
'unti \-
O-c^k^o/Lt
FATFlKk
'•r C()untr\ t
<>I- M'TIIKr'
O^Cri'ATlON
MEDICAL CERTIFICATE OF DEATH
PATH ol' DJ-.ATII f\
(Month) A (Day)
I m;Ri:HV CI-RTII'V, rii.it I attciukd dcvcasod from
O^^'i i9o3i to LmsA^Ql XO
ii
(Vear)
til at I last saw li
LLa^/w'
T()0 H
an.l that death occurred, on the date stated ahove, at *^- 15"
LL M. The CATSI-: Ol- Di; AHI wa-^ as foll..\vs:
VxXAyC/w^YXxCry^'^^'Ot' VAAjL\a^
Mouths
Pay
//
OlftS
DlkATlON ^ );.// s
I >r RATION 3, Viars Mouths /h7v< Hours
(Signed) h\j. J
a
L>ucJi>-'
KAXk QlC) TQoH ( Addns^
"'■'-; /// V,.„ I'l r.n, i-,-o
K.<^
)v,,.
I! v..n.- a^l I
SPECML INFORMATION f'uly for Hospildls, Institutions, Transients,
or Recent Residents, and persons dving anav trnm fiome.
Former or
Isual Residence ^' " X^Vs^C
Plarp of Death
Wfien was disease con icted, \ P "H i*
If not ,it place of deatti ? ^' ^V^Ax<yVA. ' ^^.^ t ^ K.
->- < Davs
Vyj.., vn\. :]La^>..w,
Lva^
CK^xaXolL
ri.ACK OI- lU- RIAL OK RKMo\AI, DATKuf MfKrAl. cr ki:.M<i\\I.
INDl'RTAKKR Mv- 0 , VCUyi ''^^ ^<.
N. B E
stable* CA*I?«! •"^'^'•'"ntlon should b;; ciirefiilly supplied. AGE should be stated FiWCTLY. PHYSICIANS 1
son *^rf . ^^E OF DEATH in pinin trrms. that it mnv be properly classified. The "Special Inltorinritian" fo
« nyinft away from home should be fei%en in every instance.
should
r pur-
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•fi
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![,:,! I h — F No !- -f'S^^^^^-, H&P Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Ddh' Filed , \XAy<JX\.^U^ X\
lOO'A
Registei'cd J\'*o.
1127
d^,Jy\J<JU^
Dep^^t
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of S)eatb
PLACE OF DEATH: — County ofUO-'^vX' 0.;uxm.^XAicc City of ^<XyVu 0/\a)^vC^^CL
( la. 5. Stan^ar^ j
J? (^
"1.
No.
S5s(hi^u. -^
.\Xky^\Jc SU H Dist.;bet. i
IDENCE GIVE F
EAItH occurred in a hospital or INSTITUTION GIVI
and
S
(ir deathI[ OCCURS away from usual R ES I DE NC E gi ve facts called for under "special information" "\
IF deAIth occurred in a hospital or institution give its name instead of street and number. J
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
â– coi.tik
\/r\j
i.:k 111
M.mtli)
(I):iv) (Year)
1-:
>n:\.-,'v.:.nutq
MEDICAL CERTIFICATE OF DEATH
DATK Ol" DI'.A IH
Q
^<.i.K. MAKi<n:i».
nxiWHi) (IK i)i\< )Rri;i)
;itt.' in surial (lcsij.'iiatii)n)
IiIKTiM'l, \ri-:
' Si.iti or e'l.uiilrv)
,1 /.->/.'// -
/),n.
VX-CV
'Ml' ()(■•
\'nii';k
â– :i<!'iiri,ArK
J'i i-vriii-.R
"^tatf or Comitrv)
â– ^I Mi>i;\ X AMI--
"' Mi)Tiii;r
liiKTin'r.ACK
"I m<)Thi.;k'
'state or roiuitiv
KtX/»^Jl^
VCVOVCU
0
J
Mniitli) (\ (Day) (Viar)
I IIl{Ri;i5V Cl'.RTII'V, Tliiit I attcMidcd deceased from
/4^^ 1 \,p\ to LLu/O. IT. i(,oH
lliat I last saw h -'.yi •■■alive on VA.O0O ^^< Up H
and that death occurred, on the dalr stalivl above, at
" >L The CAISI-: OI" DI'A'l'll \va > as follows:
Dl'R A'ilON
CONTR [IMTol
)V(;/_v \ Mi)nths i {Days I/oios
•>^ *'t I'ATK.x
AV' !,!fJ ni S,ni !'i,ni.!r,> ^<^ )',,!>• "^
(Signed) y&^v^- v ckxx. q. 1^.'>-^-.
I lours,
M.D.
4
' ' I((0
rx.ldrrs.) lSa^'l'A\j)\\.',LCiA^-.v J-^
Special Information only tor Hospitdls institutions, Transients,
or Retent Residents, and persons dyin;] away from home.
i/.w/'//
- /I
/ h\ 1
'•J.SI <>!• MY KNOW 1,1. DC).; ,\\i) m; 1, 1 1, l"
VV. I'd Til !•:
Former or
Usual Residence
Wtten was disease contracted,
If not at place of deatli ?
How lonq at
Plat e of Death ?
Days
I'LAci; OI- m KiAi, OR rj:mm\ai.
DXTK of
(1>
n
Hi Ki \I. 01 R1-:Mi >\ \I,
"XX TQOH
>. B.
F.very item o? !n?.>rm.ition should l>- cjirefiilly suppliecl. AC;K hIv.uIiI be stiite.l i;\\CTLY. PHYSIOIAMS hHoiiIcI
state CAUSIi OF DI5ATH in plnln terms, that it mjiy be properly classified. The "SpecinI InformHtJon" for per-
sons dyinji «\vny from homo should be ftiven in every instniice.
'â– 'â– A-
• ' d
A
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H •,, 1.- X,-,. , ^ t'^:^^ HS: !• Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
J}((/r Filed, Lm^aX^aa.aX' ^l
lOO'i
Begi^stei'cd J\^o.
1 128
cL^r^^A^^^ c^
Deputy Health CfTlcer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
%
^
»5. J a
Certificate of S)eatb
( XX. 5. Stan^nrD )
PLACE OF DEATH: — County ofO/CL^ru 0 AXX^^ CU^'C^ City of UOyvu OA.<X/vu^a^^cm:)
^- ^r^hx^'^oJ' St.; Dist.;bet. — ~ and
IF OCATH OCCURS «W*Y TROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
(ino
FULL NAME J
H
yrV'Crrrvct'O \j^w^.^^Jf
PERSONAL AND STATISTICAL PARTICULARS
Moiuh) I Day) ^V( ar)
bH
)
Mnu'll^
fh>
'1 "-ncial ik'si«n);ili')n)
!;i': nn'i, \c\;
^\:'\< ..r i.'uniitrv
^
in-UACK A
''•TUKR Q I]
lUKTllI'l. \iK
'•^tatc nr C'liinlrvl
MAIDI'.X NAM}-
"' Mifi'in-.R
lilRTHI'UArK
Of ^
MEDICAL CERTIFICATE OF DEATH
Vax\
M.mtlil I
iDav^
(Year)
I in;kl{I'.V CI'iRTli'N', That I attc-ii'lc. I deceased from
LLwOQ 1'^' looH to 0-vvq 1^1
lliat I last saw li-i.. â– >* alive on \J^wCv<a,. ' >-
ami that <Katli occurrol, (mi tlic dalr ^tatL(l alcove-, at ^
Ci M. The CArSlv CM- DI'ATII was as follows:
T(,oH
\.JO\JLXyvXxX> UJ^-V<^iiL/>44
I) (RATION
y'cars
CONTKir.rToRV vJa^Uo^
Mouths
nays
a
Hours
-v-N.><nx.'CX>iuu VJC<AJL'>." o.
'"' 'I'X'riox f?)
<X^
m^XxxxclA.^
/\'' !(!r,! ill Siii) I'l iJ III I r.i â– r,,;;
or RAT ION )\'<rrs Mouths I Days ^\ Hours
(Signed) 6 . V <j xx-\.cLa\jlnj M.D.
o
-4-
SPECIAL Information <tnH lur Hospildls, institutions, Tramipnts,
01 Recent Residents, dnd persons dviny .jh.is tro;n home.
1,'. iiiii^
i hi: \MuVI': ST at I'D I-KR^ONAI, I'XRTICfl, ARS AKl-. TRri-: !•( » riii-;
in.sT OI-- MV\i<No\\ i.l IK,F. AM) lU-.I.I i:i<'
'Iiif't-iuant
-'-s
A.i.ir.-s Cj<Xy-vA^ \J rVoCtxo L'OJC;
Former or "a. , , , , ,
L'sual Residence ^Oy>^^\F I va'
Wfien was disease contra^^ted,
If not at place of deatfi?
t
\\m lonq at ^/
I'Ue of fJeatfi? ^ i'X Days
I'J.ACIC < »l- lURIAI. OR Rr'.Mo\ \1, I DXTi;..; IIikiai. or RI:M<)\'\I,
\jLT^.
INI
N. B. p.^ery item o9 informHtion should be cnrefully s-.ppli<.cl. ACJB sho.ld be stHte.l HXACTLY. PHYSICIANS hHouUI
state CAUSE OI- DLATH in pljiin terms, that it may be properly claHsified. The "Special Information" for per-
sons dyinji away from home should be ftiven in every instance.
.1
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W,v
II
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i!il5
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WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
II. :'ltli
). Vo 1 ^ •*-ti'^|.<^ lift 1* Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/)^//^w-v/rr/, LLvAxyL/^ aa I'^o'i
BA'^istei'cd J\^o.
1129
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Death
J? (^ ^ %
PLACE OF DEATH: — County
No. X\\\\J J COvM.
St; 0 Dist.;bet.l'-JiAnXL<XxLt>\.o and ^-^>^dxA.L/CyV\ )
/ IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER SPECIAL INFORMATION ' \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
' c:<>i,(tK\
y\/^
'xxXXx}
M 1
111 luKrii
'M.iiitli*
51
)' ii I
I):iv)
Mnvlll'
( Vfiir)
n,n
^IN'.I.K. MARRIKI),
W IDmWHD ok I)I\-(»Kv1-:I)
'Willi- ill social <U'sij;n;iti<>ii)
lilkTlllM.ArK
'St.itr or rourtry"'
1 \ iiii;k
l'.IKTlIl'!,,\rH
<" lArm-k
istiiu or Cnmitrv)
lilKTm'I.ACK
"!• MnTHHK
(Staff <ir Coiintrv^
d
'Y\y6^
XJU:iJO\:
MEDICAL CERTIFICATE OF DEATH
DATK OF I)1:aTH
iDav)
/90 s
I ni';Ri:HV Ci;RTn'V, Tliat I atlciukil «lc(«.;»sf.l iKiiii
LLo^.^ 1*^ 190H to . U^cvo^ xc i()0 â– '.
that I last saw h -â– '" alive on LLcvn ClO k/) ",
ami that (k-atli occurred, on the date >-tate<l ahovo, at \
0 M. The CArSi<: ()!• Dl'A'I'll was as follows:
1)1 RATION )'ears Mouths Days I /ours
C( ).\TRII5rT()RV JPsXXA^CAxvvXTk'VA./cu...*^
DIRATION
)'cars
A/o)iths
Davs
//ours
M.D.
X.hlress) lOSHVt(S<Lt c5t
Special information ""'y '"^ Hospitals, institutions, Transients,
or Recent Residents, and persons dying away fron liome.
I' in- AMovK srAri:i) i'kksoxai, i-ak ruri.AKs aki-: tkik t*» jih-:
lii.ST (JF MV KNOW 1,1: DC, K AND IU;i,n;F
"iifoiniaiil
V'Mr.ss civ I I I U J
/CXAA,'
\ dh
Former or
Usual Residence
When was disease contracted,
II not at place of death ?
How lonq at
Place of Death ?
Days
rj.ACi: (>l- lU kiai, ok ki-.movai
(Address
nAQ'."' i!i lOAi. 01 ki-;m()\ai,
'^ X 1 90 ' i
>. K. Kvery item of Information •hould be carefully supplied. AGB should be stated liXACTLY. PHYSICIANS should
HtHtc CAUSE OF DEATH in phiin terms, thnt It ms.y he properly clossified. The * Special InVormat.on »or per-
sons dyin^ away from home should be ftiven in every instance.
t t
I
■» t
ij!
I
1 tj
iUifi
(
I
i
â– J
H(«»'"*-
]i
i«
ijfiii
ill
i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
•tl' !■■Vi>
■« Ik*. I k» ■«
T^N DA^K r»P rPRTiPinATr FOR INSTRUCTIONS
/;^//r n/cf/, Uo^vuiij ao. ^'>^c>H
Ke^lstered jYo.
1130
N
"l,^rVA^^ itA>iHL Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
J? ^ 4 ^
PLACE OF DEATH: — County ofO.Ct^ 0 /vOyV^c^Ci Gty of O O-Aa. 0 A-Oj^-v^v^-
o HOt'k VJ J,CVV>Oull St.; a Dist.,bet.UAX^ and J XXvvUX
-^^ »^ -w ,,eiiAi DrcinriMrr nur facts called Mor under special information" \
( '^ :ro\^..i'iTci::.'o\Trj^'!.\': ^^.Vui^r.^.'-.o^^^i.^^'^^i "ame jIstead of stre.t and nu.ber. ;
FULL NAME
^XAJIAJL
AJs'\.\ry\.'
PERSONAL AND STATISTICAL PARTICULARS
J
\
. ! I Ml !;[KriI
C<1I,<)R
JwaXj-
XXJ>j
Month)
\'.K
o\ [ JV</<> 0
I
(Day
M.oilli-
r
Ui
5.0
(Vear)
/>ar.v
MNf.i.i:. MAKKIl-.l),
WIDOWKI) OK I)IV( tROKI)
W'vitiiii social ili si}.' iiat ii ni I
rUKTHIM.ACK
'Slate or roiiiiti \
^^VAJLCL
NAMi: ni
I'A riii;K
nik'niiM.ArH
f^i" iATin-:k
state or Coiiiiti \ t
MAIDl'.X NAMI-
'»!■MoTID-.K
lilK rilI'LACK
OF M()Tin-;K
<Statr or Countrv)
X^<X^
KXV'CL
]
occri'A'nox m
Rrsidrif ill Saii f'l iiiii i^ro J^O r.^M*
Mntith^
lh!\.
I'ln: M'.ovi-: srATj-:!) i-kksonai, rAU'iirti. \r< aki-; rKiK lo tin-
Hi;ST OI- MY KN()\VI.i:i)<',K AND IU<:i<IK.F
Hn
f'.nuant vJlLUjtcoX; \n\ â– ViT^
^.^v.*w^->^^
(Address
.HOb'lx 0 J <xa..^ol11 3i:
MEDICAL CERTIFICATE OF DEATH
DAPK c)l- ni'.ATH /O
(Month) K 'I)av) (Year)
I H1';R1':1'.V CI<:RTII<*V, That I atteiKU'd deceased from
to vAA-A.x::i^ 3lI up H.
c^
'h\ 190?
tliat I last saw h - ' alive on
ai
190
'y
and that death occurred, on the date stated ahove. at H
\J , M. The CAUS!-: Ol" Dl'-ATIi was as follows:
IjAJUAA.t
n VjCCV/'A a V<> *> W CL
DIRA riON
)'ra)S
Monllis 1 Pays /lours
^l^
I )r RATION • )V<?;-^
(SIGNED) LOrraj. ^. ti^<XA.<LOL^
Months Pays Hours
M.D.
a^TooH (Addresv.) 5 a"^ dx-^tty^N; '"'.j
SPECIAL INFORMATION only foi^ Hospitals, Institutions, Trdnsients,
or Recent Residents, and persons dving 3wa> from home.
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
HoM long at
Place of Death ?
Davs
I'l.ACl-: Ol" lU-RIAI, OK Kl-MoVAI, DATlio; IHkiai. or Kl-MoVAI.
vAaaX)l. Ov'2) 190H
QTiiDL.a
rxni-KTAKKK CI. VU . Ml^WAtv.'^x. ^ U
N. «
II \rF «hniil«I be stnteil F.X4CTLY. PHYSICIANS Khourd
Kvery item oV* information nhoultl he curefully supplied. A(.F. shoulU »« stnteu .. w ,„j„„„„„:on" for Dt»r-
«tBte CAUSE OF DEATH in plain terms. th«t it m»y be properly classified. The Spe.inl Intormation for p^r
â– V.y
«tBte (rfAUSt: UH L>t A IM in pi
sons dyinft away from home should be ^iven in every instnnce.
, tl
1
T
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» f •
^&fi
!-'
.;â– :
'
m
I
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I?
^.v
i
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I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
J)
• • w t ^1 ■«
• PB -rn BA<«w rtc rPBTirir.ATr PQR INSTRUCTIONS
ill
Re^lstei'cd vVo.
i 131
iilc Filed , ux^i-^-^ '^'^ lOOH,
,trv^ i^v^ Deputy Health Officer
DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( 'CI. S. Stan^ar^ )
PLACE OF DEATH:— County of Cj/aA\J 'J .MX/vvtV4C(iCity of OxX>v jAXXyrxX^UL-cc
^
'««,
,.ll).
X ()l:^cK4\v-t<xit.;
Dist«: bet.
and
/ ,r DE*TH OCCURS AWAY TROM USQAL R E S I D E NC E G. VE FACTS "'"h," ;*>"";*"; STR^tl^iN D 'n°U M bI R^"' )
(, ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
^J^JsX.
N.'
PERSONAL AND STATISTICAL PARTICULARS
1.x A ^ ^ I COI.OR
\\J^
Xjl
DA IK »)I- IMRTII
A<".K
LL>^^KA^\^
Month*
O 1b lV,;».v
<D:iy)
M,. tit lis
(Vi-ar)
Da ) :
^IM.i.i:. MAKRIKI).
\KII)<»\VHI) OK I)IVi)RrHI)
Wtitt in sot'ial <lfsi>j;nation)
lUKTMl'I.Al'K
•stati- or Conntrv^
NAMK (M
FATMHR
HIRTHI'I.ACK
f>I JATHKR
t State or Conntry)
MAIDKN NAM1-:
ni' NJOTIIKR
JU\\y^^^j^\^Ay'\yo^'y^'-^ cv
ii
W^K 'VN.Xr VAj^yx/
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH r\
(Month) /T
(Day)
190 i
(Year)
I inCKIUJV C1<:RTI1'V, That r attended deceased from
Cuu. I iQoH to . LLa^ci 3w0 190 H
tliat I last saw h '.-> ahve on \J^^>^<\ A.. 190
J Q
and that death occurred, on the date stated above, at D
CLm. ^The CAUSH C)l' DlvATII was as follows:
â– *:
DIRATION
C
Yea'.'^ ^ Months
Days Hours
JLry:y^r.^K'\J^j..r.
A\X}^i
HIRTHPr.ACK
Ol" MOTHKR
(Statt or Country)
occrpA'
Kesidfd ill Sun /'itinrfsY,) " )V,ns 3 .^fonf/rt 1 " /^<> v>
Tin-: AHOVE STATl-:i) I'KRSONAI. I'ARTICr l.ARS ARK TRI 1% T« > THK
in:ST OF MY KNOWI.KDCK AND ni:iJi:F
(Inf
..mant LL. O.UL- \3 J^^ ^J^A^^CcL (JV) O-^ !|A.Ct>CxjL
( Afldress
..Dl.-«-
DURATION }'i'ars H Jfofi/ZisX^ Pars
( SIGNED )"o . VJ OAJkiA^ oU-cuL(: > .
Hours
M.D.
JU<\, %^ TQo't (
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Rfcent Residents, and persons dying away from fiome.
Former or
Usual Residence
Wlien was disease contracted,
If not at place of death ?
How lonq at
Place of Deatli ?
Days
ri,ACE OK HIRIAU <>R RKMoVAI,
INDKRTAKKR
(Address
DATKof IMKIAI. or RKMOVAI,
LLov-Q X?^ I90'\
U 1 cx^
M k
N. B.
-F.v.r, 1„„ o< i„!„.„».i.n .hou.d be cnr.SuM, supplied. AGB .h.uld b. .....d EXACTLV , P"^«'<;'*?!''j''::',t
Mate CAUSE OF DEATH in plain term., th.l it may b. properl, cl...l«ied. The Special Inform.t.on far p,r
Rons dyinft away from home Rhould be ftlven in avery Instance.
•!
I M
^M,
' t
( '
Ik
r
I'
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
, , , ,, i- x„. , , t"'^^»-> BSi V Co
Jhi/r AV/r^/, lixAwCuv^Aij ^Ov W0\
Juyv-u Deputy Health Officer
Ilegistercd J\'*o,
1J82
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccttificatc of S)catb
( *a. S. StanDarO )
J?
(3i^
PLACE OF DEATH: — County
of 0,ay7v J A^Ol^vCULCc City of Oo^^^' ^ XxX/-^^^ci,^^.<i..€
il)
^No.
CK^K^^^- St.;
-Dist.; bet.-
and
(••c>iiAi DC-e I r\r Nrr riur TACT^ CALLED POP UNDER "SPECIAL INFORMATION" |
/ IF DEATH OCCURfk AWAY FROM^USUAL RESIDENCE GIVE FACTS CALLtJ? .^oTFAn OF STREET AND NUMBER /
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
M,\
I>.\1 1-. (»1- ill K Til
PERSONAL AND STATISTICAL PARTICULARS
COI.oR
'V'W^
M-
10.
A(.i-:
5.H
)•,-,/*
<I)av
M.tnlln
/ ^*^C ....
(Year)
io
Ihn
MM. 1,1*. M\RkIl-:i).
\vii>(»\\i.:i» (Ik i)i\'<)Kri:i)
'\V;itriii social il(>^i>.'nali<>ii)
HIK IIIl'I.xrK
<Stat< ur C'umitrv^
1- \Tm;K
I'.iKTuri.Aci.:
oi" i-.\rm-,i<
(Stale or (.â– oiiuti \ )
M MDI-.X NAM)-;
"1 M<fnn;K
iiiK rm'i.ACK
oi- M()Thi.;k
(Slatf OI Coinitrv)
^TOUOj
7 ^
cxAAAA^ â–
f\i'M(!fif ill Sail I'liiiiii^rn J,H IViMa
M.'iilh-
l),i\:
Till". \n()vi<: sTAri-.i) i'Kksonai, par ruMUAKs AR1-; rKii-
l!i:ST OI- MV KNdWIJ'.lX,}-: AM) Ml-;!.!!'.!'"
I'd I"!!!'.
'IllfiiMllMIlt
C,(?,%, (!LvX
' \.l.lu-ss
\
MEDICAL CERTIFICATE OF DEATH
DATE oi- i)i;.\Tn r\
(Motith)T (Day) (Vt-arl
I HKRI^HV CI;RTII''V, Tliat I altcMukMl (lecoased from
OwWvA^lo b iQoH to LLvwq. \% upH
LL*.Ax:^ \L up 't
b 1 90 H t(j
tliat I last saw h Ay>>A alive 011 LL^ax:^
ami that (kath occurred, on the dale stated above, at I O 0
1 M. The CAl Si-: Ol' l)i:A'ni was as follows:
^ AxJl>-t^^:iA.vJ06-slA^0 ^ X^A^
^V^V^'
o^
DrR.X'l'ION Years
CONTKIJUTORV
Moulin
Days
Hours
I )r RAT ION
(SIGNED)
»
)'rars
fhivs
/fours
M.D.
CLu) gfe TOoH f.\.ldress)Utu^U) JbM.)tA.t
SPECIAL INFORMATION "niv lor H^spitdls, Institutions, Transients,
or Recent Residents, and persons dying away from home
Former or 1 u (VVl ^ , ""i( ' ""^ '""*' '*
Usual Residence » v M I UXA^rYu O
When was disease contracted.
If not at place of death?
i Plare of Death? '^H Days
l'L\CF ol- IMKIAUoK K1:M'>\A1,
DAI'}-: of Hi Kl.\i or KKMoXAJ.
(Address,. 2)Un X - I ^ ti^. ^t
I90H
N. B.— Hvery Item o^' Information •houlcl be cnrefuHy Hupplle.l. AUfi «hou.d »>««»"'*=;! J'''. i'i^'^^L InWnr»'tTun-l"*'p-r-
•tatc CAllSi: OF DEATH In ph.in term«, th„t it m«y be properly claHS.t.ed. The Special In^ormut.on ^or p-r
• *ion« dyinft away from home Hhould be HUcn in ia\cry instance.
f
.,-^
f
\*
V
U
! >
i!
m
m <
m
hi
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RITE -PLAINLY WITH UNFADING INK
1, l-So, 15 »-j.ir;;--uiM'Cn
THIS IS A PERMANENT RECORD
•r/^ oA/^w f\e rrnTiriCATr FOR INSTRUCTIONS
I E> I W I « > «••
Ddir l-'ill'il,
aa
uxj'i
Ro^i^ifcrcd J^''o.
1 J 33
cL^-AwA-Aw^
Deputy Health OPIcer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDcatb
â– a. S. Stan^ar^
4 %
J?
PLACE OF DEATH:-County of 0<Xa^^ Jx^vixc^cc^City of 0<X^^ J.;ux/>x^A^t.<
Nn. 3111 H'-'^- tivAvCnx;
St
.; T DJst.jbet.^'^'-*^*-'^*^^^^'-*- a"'^
.0 O-Laa. i
y V^^^'w ......Ai orCinrNrPriWE FACTS called for under special INFORMATION- "V
( 'iV"o7ATr^OCCU%ro\"rHO^?prT^At o%'?:?.^^'T^O^'V.Vr.;i NAME .NSTEAO OF STREET AND NUMBER. )
FULL NAME
iO^XsXAXA.^^\.:
PERSONAL AND STATISTICAL PARTICULARS
â– r
C()I,OR >
\^OJ'
, ^
^.
LLvi '-
C'^--
i).\
A I .!•:
Ill
^ t J-,-.;;
^IN' l.K, MAKKIi:!),
WIOdWHI) UK I)I\"ORri:n
Ml »in'i;il (U --i}.'n;itiiiii)
10
,>L/CL
>;i\
M..u!ll^
/in..
1^\
/',;
^^^^^
-4
'State or Coiiutrvi
Ml «>l-
I \ iii i:k
I'.iK ini'!,\rK
ft! I \i'in-K
MA1I»KN NAMF.
ni- M<»'lin".k
IllK lIll'LArK
<>I' MuTHKR
'"•■• ■'!■ri.utitrv")
X'
â– ^'
n./CrvwV^o"v
1
\]xKj^
<H\'i I'\'1I()X
I ^
\r,.i,th<
/hn
15HST oi- Mv kno\vij:i)<;h and iu:i.n:i-"
MEDICAL CERTIFICATE OF DEATH
DATK t)l Ii1:ATH
^ I
(l)av)
IQO
(Ycai>
( Month)
I mU-ilvHV CI'IRTIFV, That I attendtMl dcccascl from
CL^^O 190 \ to '^U,^^ Xi- 190 H
silivr. on V.*^<,VQ iH
that I last s'aw h
^
up
and that death occurred, on the date staled above, at
~ M. The CAl'Sh: Ol* DlvA Til was a^ follows:
^
g Aw<x€\.vA.^%JL CI-
m^
nr RAT ION Vtijus Months Havs Hours
jONTKim-ToKV Uk^v^rv^-^/c.M/0^vx^^
)'t:/?r5 Monf/i.'i Piivi //ours
M.D.
DTRATION
( SIGNED)
c.
[LA._^ax.<x>n (.\.i,iu..o i5ib U<^.^vMU^O-â– â–
SPECIAL INFORMATION '>"'!' *<"^ Hospitals. Institutions, Transients,
or Recent Residents, and persons dying away froai home.
Former or
Usual Residence
When was disease contracted,
If not at place ol death ?
How long at
Place of Death ?
. Days
ri.ACK Ol- nrkiAi. OK ki:mo\\i
.)UL/'\'> V'
O ex..
INDERTAKKR
IiATI. â– >! HiKlAl. or RI:Mo\'\I.
\sJ<^K^^.yQ 'X y T 90 ' i
N. B.— r.very item o? -.nform^tion should be cnret'utly supplied. ^^^Jj';''"/*' ^*."*"**The^*^^^^^ Information" for p!Ir-
state CAUSE OP DLATH in plain terms, that it may he properly classmea.
sons dylnft away from homo should be feiven in every instance.
i I
•- '■'J
m
â– .ti
in
^'i\
;ii
tsam
^WkU
t?
f^^^
(1
i.
f
'f t '
!•!
! i
WRITE PLAINLY WITH UNFADING INK
Bonrd
i- \(>. i^ â– *4.'*''i^' "''^'' ^'"
THIS IS A PERMANENT RECORD
.«« »./^L# Af> /^e-B-ririr^ A-rr rrtR I N^TPIJCTIONS
ncrcn i v» tar^wtx ><• *-<
n
nlr /v/rr/,(l^<^.cvAtr aa i'^O'i
lleiistcvod JVo,
I J 34
-f - n[^ Deputy Health Officer
DEPARTMENT dp PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( tl. S. StanDarO )
PLACE OF DEATH: — County of
J op ^ '^
0 a'7\j 0 ;uam.cc^a€ City of ^ -co^^ 0 ;v<x/Yvev<L-c.c
Ch^'
i\j>Jt^-Ow/\.;
St.;
Dist.; bet.
and
r^.UAj V \AXj\X\A ^^ *^^^^T^^^ ^J"' ., or«?YnVNCE GIVE facts'called for under "special information- \
FULL NAME O^tW^'tv^ 0 m2A^.a/Txu
/CUlA-
A
vmJU
PERSONAL AND STATISTICAL PARTICULARS
COLOR N A
I»\ n. ()|- HIKTII 0
M.mihl
\i . 1
HS
yra>>
10
(Day)
M.nilh^
:ic
fVc.-ir)
Day
MN<.I,1':. MAKUn:i).
\V!i>n\VHI) Ok l)I\'t)Kr}: I)
' 'Ml in >.(Hiiil (Usiv:natit)ii)
HIRTHPI.AOK CT\
(State (ir C..uiitry»{J|l
J /Ow(y>VOu'YV^ dwlX^CXX; CjX'O-
\ \M1-. OI-
i-.\'nii:K
niKTHlM.AfK
oi- i-\ihi<:k
(State or Country')
MAIDKN NAM1-:
'»)• MOTIIKR
HIUllll'LACK
<>»• MOTHICR
(Slate or Connlryl
1
/CLCy^vOu^'Vo
Kfsidrd in Sau f'l ann'si^n \ I )'<\n <
\r.:n'li'
/)./!
nn: \hovi-. srAri:i) i-kksonai. par iiiti.ars akh TKrH to tii»-:
i«i':sT oi- \iy Kx»»\vij;n<'.K and hi:i,ikf
:mt J . 0 'OXIA VO^^WJ
(Info
(Address
XW 'j<x.cJL'C ot
MEDICAL CERTIFICATE OF DEATH
DATIv OI- Dl'Aril r\
(Month) A^
1 HI':RI';HV C1*;RT11'V, Tli:»t I alloipkd ileccascd from
(Day)
l9o\
(Year)
1 90
to
^90
that T last saw h alive on
and that death occurred, on the date stated above, at
M. The CAISIC Ul' I )i: ATI LNvas as follows:
nr RAT ION Years
CONTRIIUTORV
Mont /is
Days
DTRATIOX
(SIGNED)
Pays
)'rars Monl/is
Hours
Hours
M.D.
LfrVtrvAjA^
-vcx
SPECIAL INFORMATION only lor Hospitals, Insfitulions, Transients,
or Recent Residents, and persons dyinq away from fiome.
Usual Residence laiU'.C^ vc dl Se'7oelth?
Wfien was disease contracted.
If not at place of death ?
Days
I'l.ACKOF lU'KIAI, OK RI:M<>V\1.
DA TK of HI KiAi. or KHMi>VAI.
1 1-. o;
cu
IN. B.
... *np „u„,.i,l he «mtecl BXACTLY. PHYSICIANS should
of informntlon should be carefully supplied. AGE should ''« «*"**^/:''.!'^ * ^^^ Information" for p.r-
E OF DEATH in plain terms, that it may be properly class.V.ed. The Specal Intormat
-Hvcry item
state CAUS
sons dyinft away from home should be feiven in every instance.
•I
I .
|l«'^
?»1
♦ '
11
*ff
W rt*=ssammmtKmm
â– FM^^TWW^lWW
If
1
I* 1
^â– l
n .
â– i
*!]
«
-1
! .i
i 1
i
1
1
t
i
t
1
(
'
(
1
1
I t
Mthtn I O OM«^r\ \Jr v>L.ri
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
B«,rd of Hcnlth-F No- i^ 1^^J^ H&P Co
Dull' FilOtL LIXA-XVL^AAJ XX li)0\
D iMe-rQiir.TinN<%
Be^isfered Xo.
II -js
0\^^y\J<./<^
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH==City and County of San Francisco
PLACE OF DEATH : — County
Cevtificatc of 5)catb
( 11. S. StanOarD )
J? (^ \ ^
of C) .Ol y\j J AXX^-rxCAA ccCity of O/CX.^ 0 AXl^tv^la^'Ci^.
J^<xX)
St.
Dist.;bet. —
and
\.AJ^\.A>^ OPCinFNCF GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION' "^
( '^ rF"4rH^occu%*Riv,;''rHo"s"rAt :^v.i]rr^.^.oro.:rs.\ name ..steao of street a.o .umber. ;
^0 V^ji^/^axxaA-o
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
",11< 111
\Xy-wsJÂ¥0-^
(M..nlh>
'I
0.5"
J '/â– (,' I
(Dnv"!
Mnilh
r
I Vfai)
na\
^iNt.i.iv M\Kun-.n
wiix'U i:i» (IK i)i\<>Kt*i:i)
icial (li'iij.Miation)
lUK run. voK
' ^i.itr 111 1 '..iintrv^
\kjy\)^
\ \Mi: oi'
lAiii i.k
HIKIIIlM.ArK
Ol' lAIMIKR
(State or Coimtrv^
MAIUKN NAMH
Ol MOT I IKK
HIK llll'l.Al'K
• '•' MoTllKR
fSiiiic or c'oi.ntrv^
h'f-^iilfil III Sail I'l i> I'l I ^rn
vv^^s-^v,^^'
\«
<l
5 V'(? /
\J,.„th^
Pav:
MEDICAL CERTIFICATE OF DEATH
DATl-; t)l'" DI'.ATH
a
(M..ntli) jj 'I>''y) 'Vear)
J IIIvKl'lHV CI'RTII'N', Tliiil I atteii<lt<l <Uri;ist'<l fr«»iii
10
Day)
LLtv
^
b
190 s
\XxA.AX^
to VAAA./CL. XO
tliMt I last saw h A. , ,x alive on ^^^^ ^^ up 1
and that <Kath orciirrcd, on the .late state-l ahove. at 10, HS
0. M. The CM" SI-: ()!'■I) I •: A I'll was as follows:
Months
„rKATK.N Vr^ -
CONTRII'.r'lOK
Pays J Ion IS
oJ\/:^<x^
1)1 -RAT ION Vrars
(SIGNED)
'11 Uyo\ (
\\aLJ^W
Mitnt/is
/hrys
//ours
M.D.
\.l(1ress)g1jAI'^<X.>UY
^TION "n'y l<"^ Hospitdls, Insfit
<fv:'0-^\t
SPEd^lAL INFORMAT
or Recent Residents, and persons dyinq dway (rom home
When was disease contracted,
If not at place of deatli ?
^tutions, Transients,
/U
How long at
Place of Deatli ?
Days
111, .VllDVl', STATlvI) I'KKsONAK I'A U 1" I>" T I,,\ K S AKi: I' K ' I'". Tt > I" HI';
IU:ST Ol' MY KNu\Vl.i:i)(".H AND lu;!.!!';!'
(]
'r'lnanl LAxX^k^AAj vJ . \lR vi.
Ct
)
(A.1<lrc-ss Ofc.MrUxAj^ (]\0{y<J^JlxX.l
l'I,.Ul': Ol' lUKIAI, OK KI.MOVAI
D.\ri', ol lii KiAi. i>r Kl-".Mo\'AI,
!1
^^
%
? J
I90H
<XOL.-tX-
ind1';ktaki:k o v-x>^wN-v-y - ""^^"^"^^
^ „ ^ TT^ ,. , Arr «»v) lid be Htntc.l I.XACTLY. PHYSICIANS Hhoiilcl
N. B.— Hvery Item o? in?orm«tJon «houl.l be .i.rofutly HuppI.ed. A(.l. s^ , ' !^fjL The "Spcciul In^ormaHon" for pT-
stntc GAlISn OP DEATH in plain terms, thnt it muy be properly ciussineu.
son* dyinft away from home Hhould be ^iven in every instance.
Mi
I
â– ii
M
1 r
: "3
m
'f,i
ill
I
M
tr<
'^— »-
liipf
n
I
\
â– ^1
11 .'«t
''I
I
i
â– M
^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Ho:n.l ..t lI.Mtth- V Vo. i.?t;??:^^"^'-^"
â– rrk oari* nc rrPTIPICATE POR INSTRUCTIONS
!)f,fr /v/f>r/, (XvUVL^ ^Xa ' lfW\
Bo^istei'cd J\'*(),
11:36
ca^^t^-^^^*^
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( XX. S. StanC»arD )
PLACE OF DEATH: — County of \llx/\^<X.cLa City of 0 /bO^U.
St.
-Dist.;bet.
-and
^0% ~ ~ ,,eii«l orQTnPNCP GIVE FACTs'cALLED FOR UNDER "SPECIAL INFORMATION' \
FULL NAME CJcn^
t I
I :l
' \
â– 1 \
PERSONAL AND STATISTICAL PARTICULARS
coi.oR p n
1 , _ I
C^'^wL
tM<.nlli>
\' 1
5^
) I'll)
(Day)
M.nilhs
'Vt ;irl
/'./!>
WIDoWKI) (»K I»IV()Kl"l-:i)
i W' â– -' irifil cl(>.ij.'iiat ioii )
IlIK riU'I.ACK
(SUito or Countrv)
I'.\T1I]:k
HlkllU'I.AOK
*>'â– ! \riIKK
' roiuilrv)
MAll)i:\ N'AMK
<>!â– MOTin<;R
HiK rni'LACj-:
OI- MOTHKR
'Stntf or Country)
>^Oj
9
Ac/\\^<X
ucri'i
f\^>iil/'(i ill Sail /'i <iiit isi'i} '" ) iii i
.!/-/;////<
â– 'iii: \U()VK sTAri;]) rKusoNAu rAKiuTKAKs AKi: rkri-: i" ii"'
Hi:ST Ol' MV KX()\VI,i:i)C.H AND HI-.I.n.F
'I"fo:ni;nit
AJLa.^^^-0''\MXA -^UjEK. » ^ N-vL
'Address
,1
— lJ — :
(ICAL CERTIFICATE OF DEATH
MEDI
DATK <>I' I)1:ATH /O
(Montht r
Day)
(Year)
I H1';R1':BV C1:RTII-V. TIimI l Mtti-iiiU-il deii-a^ol from
— [ lip to ^^P
tliat T last saw li ":: alive on ~ ' ^9°
aii.l that (loath occurred, on the- .late- stati-d ahove. at
M. Tlu- CAl'Slv OF l)l{.\ril w:»s as follows:
1)1 RAT ION )V<7/-.?
CONTRIlUroRV
Mouths
Days
Hours
Years Months
I )r RAT I ON
( SIGNED )
Days
Hours
â– ^
M.D.
Special information only for Hospitals, lnstitutions,'Transienfs,
or Rci enl Rfsidents, and persons dying away from home.
former or
Usual Residence
When was disease ronfracted,
II not af plare of death ?
Hew lonq at
Plare of Death ?
Days
I'l.ACl*, ol- lUKIAI. OK KHMo\AI.
r:
I)Al\Hof 111 KiAi. «)i m.MoXAI.
(Adilr.'ss
iv.i AGB 8'noi.kl be stnted EXACTLY. PHYSICIANS Hh.u.1.1
'^' K" livery Item of inform
state CAUSE OF DEAT
Ron« dyinft away from home shoulil be ftiven in every instance.
i^
I
M
< ' i 1
Hl^^
f
i
! , ' ^ HI
>dUbi*«MpawMta
;(l
<<
)
^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
ivvii.1 of Ht;.UJi- » No 1.; -^^^^ H&r Co REFER TO BACK OF CEWtiriCATC FOR i niaTRUCTJuNS
IX, Ic /'V/^v/, LLu^.oM.^^ 'XX lOO'i
Ttegistcred ^'"o.
11.37
cL'^'LA.A^
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( la. S. Stan&arD )
J? <?5p -5 (5j)
PLACE OF DEATH: — County ofOaAAj 0 ^vao^x^AAC^ City of 0 ,0^^ 0 A/O/wc^a ^
No,
. JJA.'>v>.xx/>^ ubc^^^AjL'
St.
Dist.; bet.
and
/ \T DEATH OCCURS AWAJ FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION * '\
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
•-I A A I COlA)R
T\^ ()bxa'AxiAAyCL^l.<ix->
I' ^ : r ol- lilKTU
iM.mth)
\ < . !■•
3^
\ ra ) >
I
•^IN'.I.i:. MAkKIKI)
W MX »\yKI) OK DIVORiKl)
'N\iit( in social dcsijniation)
'A^
luk rMPhAi'K
(Stall or Country)
I'ATIII;r
lURTlll'i.ACK
'>!• lAPHlCR
'State or C'ountrv^
MAII)i;\ NAMK
<>!• MOTHKR
HIRTHPF.ACK
<>i" M<)Tni':R
'St;itc or rouiitrv'l
•»CCri»ATlON
(^
(Day)
Motillis
A.
(Yiar)
fhi ys
MEDICAL CERTIFICATE OF DEATH
DATE Ol
LLu^Q
(Month) \'
11
(Day)
190 I
(Yenr)
I IJIvRinJY C1':RTIFV, That I attended deceased from
that 1 last saw h v^iv*. alive on
\.X 190 H
to
T90
and that death occurred, on the date stated above, at
y M. The CArSr: C)i' DIvATH was as follows:
\i ]\<xJL/CO\y<^o^
/ yr\^.0..
nr RATION )\'ars Mouths iO Pays Hours
CONTRIHUTORV
M
Hours
M.D.
DURATION Years Mouths Pays
(SIGNED) . G. ly. \tllu>V.«J^.
LLccq ai 190 M (Ad.iress)IS ( 9-<.UXf.;v Jl
^i^AL Information only for Hospitals, Institutions, Transients,
fy'e.^iiifd in S,in /'laniisio O )V<mv "^
MnlllllS " Hti 1
"'nrJ-r*!?,^^,T'^''*''"'* '"HKSoXAI, I'AKTIcr I,A KS A R !• TKrH T( » TFIH
lll.Sl ()|. MY KN()\V1.i:d<;K AM) HKMi:i-
' \(Mr
ess
SPEC
or Recent Residents, and persons dying away from home
Usual Residence H 11 U/CU:VA/>>UA\A(i;H place of Death ? t
When was disease contracted.
If not at place of death?
Days
I'l.ACK Ol' IHRIAI. OR KKM«'\AI. J DATllof HtKlAl, or KKMOVAI,
Kxxy^xx \^^r^ZA\^\.^o^M^^
(Ad<lrrss..'i.lB.. "u dfU^^ v v) /CxXjL LLv
N. B.
F.very Item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
•tate CAUSE OF DEATH in plain terms, that it may be properly classified. The '^Special Information" f«r per-
sons dyinft away from home should be 4iven in every instance.
m
\
'1^1
!1
I '^
ii
I 1 11
1
♦ (
F'^^
;!
^'^ftf^m
fMT
«#
^â– 1 r:,
â– â– I-
»!'
If'
i
1 '
i
*l
h â– i
h
' f
I
'•4
WRI
TE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I !l<;ilth - »•" No. !«;
nt.rt.n iv
?,!!
n
i ^i:
Ihf/r Filr(/,
Registered J^o,
i i m
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( "CI. 5. StanOarO )
PLACE OF DEATH: — County ofO-CL^^ J vVo-^v^a^co City of 0<X/>v 0 Axx.>v/aoQ. ^ (
INb^OwLJUvYVvXX) K^Lr^\jiX.oS: (lb^^4^.iSLA-l Dist.;bct.
and
ll/' \r OtATH OCCURS AWAY FROM USUAL R E S I D E N C E Gl VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
IjV If DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
0
"^ KjJLrr^\.0
PERSONAL AND STATISTICAL PARTICULARS
'"Y?^ ^ I coi,()R'
I>\ II-; III- MIRTH
A<.K
©^
I Montlil
(Day)
/111
(Year)
?^l
Viii I .
10
r \ I
M.mths .K \ Ptir:,
SIN(.I,K MARKIKI)
\VII»( »\\ HI) OR I»IV(»R(.'KI>
tWriti- ill social dcsit^tiatioti)
lURTMIM.ArK
(Sl.itc or (."ontUrv)
N'\Mi: Ol-
I ATI IKK
niKTllI'I,A(*K
<»F l-ATMKR
(State or Oouiitrvl
MAIUHN NAMK
Ol- MOTHKR
I'-IRTIII'l.ACK
•»!•■MOTHKR
'Statt or Comitrvt
"^ <l TATION
/VCX/wcLl;v'
lU^iKAj
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH /O
LWq iCi
(Moiitli^r (Day)
I IIIvRIUJV CICRTIIV, That I attemUd (Iccoascd from
— to —
(Year)
I9O
that I last saw h^:r- — "alive on
iqo
190
and that death occurred, on the date stated above, at "
^^ M. The CAl'SI-; UI- DI-ATII was as follows:
1)1' RAT I ON Years
CONTRIIU-TORV
Mouth%
Days
/Jours
DURATION
(SIG
I /ours
}'i'ars JA'/////.? /)avs
<X/'v\xL M.D.
Rfyidfd ill San I'laiiiisfo 0 XH )'iai s
Mniltll>
rhi\
III)-: AHOVKSTATKI) I'HKSONAI. I' A RTICl' h \RS A K 1'. TRrK TO IHK
ll»:ST ()}• MY KNO\VI,Kn<;K AND HKMKF
(I
( A<lclrcss
NED) Wun^JlA^ J
SPEC^'aL Information only lor Hospitals, Institutions, Translfnts,
or Recent Residents, and persons dying away from home.
Usual Residence 3. io CuJULKXX. cH-
Usual Residence
When was disease contracted,
If not at place of death ?
How lonq at
Place of Death ?
I'LACK OF UlRIAI^OK K1:Mo\AI. | I)ATi:of Hikiai, or KKMOVAI.
ic...-,. i '-^^^
l-NDKKTAKKR vJ J'ViUrll^^^ JjAxOk^
(Addrt-sv R5"n. \irtv<L<S.V<r-kV c5X^
M. B.
Bvery Item o? Information should be carefully Hupplled. AGR nhould be stated EXACTLY. PHYSICIANS should
•tate CAUSE OF DEATH in plain terms, that it may be properly classified. The * Special Information f«r psr-
"ons dyin|l away from home should be (ivcn in 9\9ry Instance.
; {
>
i â– 'â–
^Bj
1 •
'\H
I â–
I
%
it
I
/*â–
-J LJUl.
.^
J..I
14
'}
"I
WRITE PLAINLY WITH UNFADING INK
.• 11- allli" !• NO. \--
^ f^T"*^
iJl.V 1 VI)
THIS IS A PERMANENT RECORD
/^//r /v/^v/, lXcv.qA.\At7 a3L i'>'6>H
0^.^^ JUam^ Deputy Health Officer
Ilogisfcrcd J\'*o,
i j ;39
DEPARTMENT OT PUBLIC HEALTH^City and County of San Francisco
Cevtificate of Bcatb
( 11. S. StanDav? )
PLACE OF DEATH: — County of C! Ol^^ JX(XA^ec<LC.c City of O^Xaa^ vJ.\Xl/rvc\^^c
,Q
/No. ACiM VXo-y'vLr>Aj VJ OaJK St.; '1 Dist.; bet. UaaJXAJLA^ and cU CTUVjL^
/ ir DEATH OCCURS AWAY FROM USUAL RESIDENCE give: facts called for under "special information- "^
V, IF death occurred in a hospital or institution give its name instead of street and number. J
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
COJ,()R
,aU)
^^H'
â– >]
i'\ ; 1, « 'I iiiki'ii
1%^
kjL
)â– /â– ,;
(I):iv)
M.nilh^
(Year)
/5,;i,v
>^IN«. I.l- M.\KUII-:i)
\V[I)u\\):i) OK l)!\-nKr|.:i)
' \^' ' 'â– â– i -1 -' '<i:il <lf^i;Miati'>ii)
'Statior r.iiiiitiyi V \ij\]
A/^'-voAx
NAMI-: ol-
I'A riii-.K
niKTilI-I.ACK
'>'â– I \iin-;R
â– "' 'â– "t Cduiitivl
<'l Moi'IllCK
'ilKlfll'l.ACK
;>1- MOTIII'.R
'^t.itc or Country)
MEDICAL CERTIFICATE OF DEATH
i).\ri'; Ol- i)i;.\rii
^ 1
(Montli) ,4
I Ill'klinV CI^RTII'V, Tliat I attc'iukMl .Iccoased from
(Day) (Year)
I9O to
lliat I last saw li ~ Jilive oil
ami that di-ath orciirrcd, on tin- dati- stated aliovc, at
M. The CAISI- Ol" l)i;.\TlI was as follows
I(>0
T90
) V
I) IR. ATI ON }'riirs
CONTRHU'TORV
Mo)ilhs
Days
Hour
DIRATION
)'t'ars
^^<luihs
l\r\
'V
( BIG
NED) ytPV^V' J OxsJLX.
IL - - ^ â–
a
XX
A^V-CX ^
nou}s
M.D.
TQO
\ (,\d.lrcss) 'bHlb ^ \\
il clt
Special information ""'^ *<••■Hospitdls, institutions, Iransicnts,
or Recent Residents, and persons dying ciHdv frotn fiome.
I'm: \ito\-i.-, s'i-\ ri: I) i-kr^on \i i- \kiut i, \ks ari-: I'Ri r: To iiii-:
l''l.M" O! MY KXOWIJ-.DC H AM) lUlMl'.F
Miif,,
lUMTlt
Former or
Usual Residence
When was disease contracted.
If not at place of death ?
How long at
Place of Death ?
Davs
I'l, U1-; Ol' HiRiAi. OK ri:mo\ AI,
I) A'n-: of III lu.Ai. 01 ri;mo\'.\i.
N. B.
— Kvery item o>' information hHouUI b. cnrcV'ully supplied. A(.'B Khould be stnted RXACTLY. PlA'SICIANS nhould
«t«te CAUSE OF DFATH in pinin terms, thnt it m»y be properly classified. The ' Special InVormation *or per-
sons dying away from home should be ftiven in every instance.
fc
\^
I ! !^'i
- J ^ '
r
«.
; ♦ I
il^ii,
l! :J
I
*»#^
i
t> '
i
"y.'
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Board of Il.altn I- >o. i-^ ^-^-ugrg^ n<.^ i y.
n»f«ipn -^/N B«r>i« /nc r< p B<ri Pir> ATP rr%B l NQTBIir^TinN^
11 i^# •rf*-*^*'^ ^i*«
RegistcTed J\^o,
1140
/>,^/(' /-V/^v/, (Xu^^cM^^tr 'kX lOO'K
JLfroc^ XiL^ Dteputy Health Officer
DEPARTMENT OF PUBLIC BEALTH=City and County of San Francisco
Certificate of Death
( tl. S. Stan^ar^ )
PLACE OF DEATH: — County ofOcL^X; 0 A.O^^vil<>ie(. City of Cj.O^ao^ J.KXLo^ca^^^c^
(No. I'iHt JA.Uv.Iv St.; ^ Dist.; bet. 1 JuUvvc^a . and IbxlvAA^'x. )
/ ir DEATH OCCURS AWAY FROM USUAL R E S I D E N C E Gl VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION- \
V. IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBEJR. /
FULL NAME
DOU CLCL^.-U;
M.\
PERSONAL AND STATISTICAL PARTICULARS
J COl.OR
OX/YWoJui
1)\ i ! ( >! lUK'I'H
Ai.K
a,
|^t(.uth) II
i V(j J
M.»,l/,.'
Pa Ys
SIN«.1.K. MAKkn:i).
WHxAVKI) OK DIXOKii:!)
iVViit< in sorial (l<>«iKiiatioii)
HIK rm'l.AOK
'Stalf or Comitryl
4
^
0-
NAMK or
»ATHKR
HFRTHl'I.ACK
0|- I-ATMHR
(State or Country^
MAIUKN NAMK
<>» MOTHKK
HIKTIU'I.ACK
»>»■■MOTUHR
(State or Conntrv^
OCCri'ATlON
_ Rfsidfd ill Sail /'imiiisri
,Ojy\j 0 A-XX/Y^'C.'L.^ c>c
k}crU/txxL
-tr
MEDICAL CERTIFICATE OF DEATH
DATK OK DKATH
(Day) (Year)
A^-LO
(Month) K
I HI'lKliRV CIvRTIl'V, That I attendtMl (Icci'ased from
I90 * to
tliat I last saw h :• alive on —
I90
ii.yo
and that death occurred, on the date stated above, at
M. The CAISH OF DIvA Til was as follow?-
; JlJi'w^z.:
f L<xaaa.<.
V<X ^\J
)V'(7i
DIRATION Years
CONTRIIU'TORV
Months
Days
Hours
}'rars
.^Tonths
Davs
M,>iilhs
/)<M.
TMi; AUOVK STATJ-l) I'KKSONAl, PARTKT I.A KS A K !•; IKrK TO THK
HKST '>i- MY KNowi.Knr.E AM) in:iji:K
(Aclil
rcss
DI RATION
( S IGN ED ) L'V . M LvaJ\>^K a.'Lo^
10 iqo H ( Address) HClM (kI B.t
Hours
M.D.
SPECIAL Information only tor HosplUls, institutions, Transirnts,
or Rfcfnt Residents, and persons dying away from home.
Former or
Usual Residence
When was disease contracted.
If not at place of death ?
How ionq at
Place of Death ?
Days
PI.ACK OF HIRIAU OK KHMoVAI
rNDKRTAKKR LV>\^\-
190' I
(A<l<lr(•^s
DATK of Hi KiAi, or RHMOVAI.
N. B.-
-Rvery Item o? information .houid be carefully supplied. AGE should be stated EXACTLY PHYSICIANS should
state CAUSE OF DEATH in plain term., that it may be properly classified. The Special Information f*r per-
«on« dyin^ away from home should be t'ven in every instance.
n
\%
* *l
m
I' ; 1*1
M . . ,
il
,i'
<
m
n.
'â– 3
It
'f.
â– i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Hn;ili
1. -th V No-
/;(//(â– /-'//(v/,
ax
7-9 (?S
Rn^ififcrcd JVo.
J 1 11
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH==City and County of San Francisco
Certificate of IDeatb
( Xa. S. Stan^ar^ )
PLACE OF DEATH: — County ofOcuo^ J;\^cv>\.-cui.coCity of CJ/O^^^aj J.\-XX.^ vc^^iL^-e.
•C)
No. ^"iO db/a^oAx
-t.
St,; S Dist.;b€t.MD-U.-^\va.>^^Avand tUJL
0.
/ IF DEATH dfccURS AW«Y FROM USUAL R E S I D E N C E G 1 V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION • \
i, IF DEATH '^'-^"«»'"^" IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
V
PERSONAL AND STATISTICAL PARTICULARS
I) \ 1 i nl- lilKTJl
I Month)
Ac.i-;
SS
) ra
0
(I):iv)
Mnnlh-
4
(Vrar)
/'</ 1.
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH
a
.c\x:i
(Month)
T
11.
(Dav)
(Year)
'^IN'.I.K MARKIKI).
WlDoWKD OK i)[\-( »Kvj.:i)
' \^â– 1' in >-'n-ial (lfsi;.^iiatiini)
HIKTm'I.AOK
(Statf ur Cunntry)
NAMl- ( !••
i-.\Tin:K
nii<TiiiM.\i"K
'>l' I ATIIKK
(Stal<' i)T (."(iiiiitrv
m\!i»i:n nam 17
"IK 11 IP LACK
<V" MOTHKR
'Statf or rouiitrv)
OCCri'ATlON
SI (^ fi
i
•t,
./OLXUyYV^' Vv^co-
1 iUvUIUiY CICRTIFV, That 1 attLii.UMl (Iccoased from
skx.-^' 190 3) to LXa^cl XI TOO H
til at I last saw h .^â– "- alive on OL^-vO 1 X
I()0
and that death occurred, on the date ^tati-d ahovr, at o
VJ M. The CAlSh: ()!• Dl-ATll was as follows:
.CL-Lxrvvv
.t<V*v Q>aA^\.^X
XOv\,t'
u
S.<'E^V-J?^>V^<J <^ vvt^
1
DTK AT KIN • )V<7;-.s' Months
Pays
1 1 our Si
CONTKIHrTORV
Dl'RATION >''''^''l
Months
PiU
.'S
(SIGNED)
LXXA./>A.AAJ-trtKL
Ilours
M.D.
a
RrsitU'd iu San I-uuu iy,:^ x\ )>.?;> 10 Mo<itl,^ '^\ /'.n>
in \iu»vi*. STA ri;i) i'kksonai. i-ar tuti.aks aki-; TKri-; lo tin-
''■I.ST ()!• MY KNOW I.KDC.H AND HKMl'.F
'I'lf'JMnant
(Addri-ss
ECmL INFO
(Address) cLoL'>\JL fo 0KlK.v1<<X.L.
SPECf^AL Information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
Former or
Usual Residence
Wfien was disease contracted,
If pot at place of deatli?
How long at
Plare of Dealli ?
Days
I'l.ACH ()!• jn KIAI, OK KJCMOVAI. | DATJ^o!" It! lOAi. or KHMOVAI.
ri.Aei-, oi' ji^
mm
1 I', o: II
rNDKKTAKHR J J\JL>Crt^.-'e^.• '^AJL/Of-Ui
^
'^'^
TQO
. oV' informB^on\hould be cnrefuHy Hupph.cl. AGR «ho:.l.l bo Htatec. F.XACTLY PHYSICIANS nhould
^E OF DEATH In plain terms, that It m«y be properly .l»«Hi)flcd. The Special Information for p.r-
«..._.. i?_. 1. „u I.I u— At.-.n in <a«/ox%/ inatfince.
'**• **• F.very item
state CAUS _„ ^ _
«on« dyinft away from home should be ^iven in every instance.
iiii:
11'
%
'â– f!
I ^
iiji'i
' Mi
( r
^1
'f"
, f
!rv
\\r ?
I
r
f
.1 :
i:i<
I
f <
T?i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
j5oMr.i -!■i!. ."Ill I- NO. !«; -v:??rr" "^^' ^"
Dc-rc-D T-r. oarK np rrRTirit^ATF FOR INSTRUCTIONS
])((
fr Fi/rfl, XXa,^^ ^X I'^O'i
Begistercd JS^o.
UA2
CMS'^w^A-^^w^
Deputy H?-.'=^fth Officer
DEPARTMENT OFTUBLIC HEALTH=City and County of San Francisco
Cevtiftcate of Beatb
( tl. S. Stan^ar^ )
-No.
rv'
PLACE OF DEATH: — County of
M. Co ibcKivd^' St,;
/ IF OCATH 4cCUBS »W*V FROM USUAL RESIDEI Ki««=-
^ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME
1
Dist.; bet. - '"• and
S AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION • \
S AWAY FHOiv. <JO««u ^ INSTEAD OF STREET AND NUMBER. /
FULL NAME
Oj\r\.6^ Vtn^Ji4'
PERSONAL AND STATISTICAL PARTICULARS
I COI.oK
^
{â– \jJ<JL
DATl, i»I- illKTll
Ai,}.;
5^
5 (•(/ I *
1
H
iDav)
M.niUf
(Year I
a
Pay.
SI\<W.K, MARK M:1),
WIDOW HI) (»R IH\OKil-:i)
'Uiit. ill -nial (U sit'tiatioii)
iiiK rm'i,ACi<:
iSt.itr (ii Ciiiiiitry^
NAMl oi'
I- \ 1 iii-;r
HlUruIM.ArK
OI- 1 \rHKK
'Stat, or Covinlrv)
MAIDI'.X XAMF
OI' MoriU-.k
'nKTin'K.xrK
OI' MOTHKK
(State nr CDUiilry)
V
MEDICAL CERTIFICATE OF DEATH
D.XTK «)!• DlvATH Hi
(Moiitli)T 'Day) (Year)
I HI'RIUiV CI'KTIl'V, That I attciKk'd (leceasetl from
W 190 H to Uvwa X\
tliat I last saw h^.\-»'^ alive oti LIaa^Ol. 'X\
:iii(l that <lcath occurred, on the date stated above, at 0 6 C
.J M. The C-U'^'*' ^>'' l)I':ATn was as follows-
1)1 RAT ION ^'rars
CONTRIIU'TORV
Months
Pa )'.?
Hours
DIRATIOX
Years
Months
Pay
oeeri'ATioN
vj\yCVAJuv.<>-0'^/<^
o^^-vd.
Kf>idfi{ in Still /â– ') (itti i>r/i oH )â– /â– (?;- Monttn
Dii
(I
III \H()V]<: sr Ai'i: I) i'Kksonai, tar rut i. \rs ari-; pri
l!i;sT Ol- MV KNOWM-.DCH .\NI) lU-.l.ll-.l-
)•; Ti> Til »•
X.Mhss a.Vj. \J^ . JU ^^^XV.t<XA
^ , Hours
(SIGNED) lU. VJ. ^ 'OJr^^y M.D.
CLa.'Q Iv ,c,oH. ( Address). O-^l l-< %(Ml1-v^U.^
^O^ A.'v i()0
:cAaL INF
i
SPEO^iAL Information «"'> for Hospitals, institutions, Transients,
or Recent Residents, and oersons dyinq awav from liome.
Former or .a \. "^ !V ..,
.U%, cH PIdfe of Deatli ?
Usual Residence ^H" i'^
Wfien was disease contracted,
If not at place of death ?
Days
I'l.ACi-: Ol' nrKiAL OR ri:mo\ ai.
OJkJLc^.
T90H
(Address
iLXTKof H. Ki.M. or RHMOVAI.,
N. ».
Hvery Itcn of Infon^Btlon .hou.d be cn.eful.y supplied. AGF, nhou.d »>««*« '-^l.f'^.^^^'*'^;,^: ,rrJtTo^„''l':'p;I.'
state CAUSE OF DEATH in plain tcrm«, thot it ,n«y b. properly classified. The Special Informat.on for p.r
son« dyin^ away from home should be feiven in every instance.
I I
m\
7 1
i
i i â–
Il t<
:ii!:
!H<''
i
JiJ
I!n:nil '■'^ 11' altll- »• >" l^ -
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
i**!ZrVx. ,.o. ,.,^ . orcro rn BAr.K OP rFRTinCATE FOR INSTRUCTIONS
i
11
4*
Begi.slcj'cd J\''o,
1113
cL^KAAl^ijL^ Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( "U. S. StanDarD )
PLACE OF DEATH: — County of
(^
<X-4^
City of^JXCL/Q^l
)XJLh
No.
St.;
"Dist.: bet."
and
/ IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E Gl V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION' \
C .F DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME
''\A^.
PERSONAL AND STATISTICAL PARTICULARS
a
COIA)K
,\iji
Ai,)-
5
(Day)
O
(Vc.l! )
Slo
) 'in .
{ M.>ul/i< 1 O
PilX:
- . • . . r . M.\KKIi;i)
\Vn»o\VKI) OK niVoRv'KO
'^^ : ' •!-■.! i:n il< ^ii'uat ion)
i'iK niiM.Aoi-:
(Stntr ox Cf)iintrv
I" \TiI l.R
UIK 1 Ill'l, ATK
<>l' lATin-K
fStal. .i; (â– ..initr\-
MAIDl'N NAMl-
♦»!• MOT I IKK
RlRTHIM.AlK
J>1- MOTHKK
(St:i«.- or Coiuitrvl
<H'^ri'.\TlON
(Day) (Year)
MEDICAL CERTIFICATE OF DEATH
DATK Ol'- DKATH /O
(M(.nth) A
I IlI'lRI'iHV CI{KTn'V, That I atteii(lc<l (leccascd fmin
up to ' — icp
that I last saw h "-- alivi- oti ~~ 19O
and that (It-ath occurred, «'ii llic dato statt-d above, at
M. The CAI'SP: OI- DI-ATII was as follows:
DC RAT ION )'cars
CONTRIIU'TORV
)'i(ltS
Mont /is
Days
I /ours
f\^M<ii'if ill Sijii /'i(in,i>i'ii
)'f n I
^r.>ntll'
/hiy
'III, \H0VK STA'n:i) I'KKsONAI, I'A K l' IT T I.A KS A R 1". TK I l-l To TH}-:
in;sT OI- Mv KNowi.Kix'.K AM) in:i.ii:i-
(II
f""ii:int \) rVoLKAyOO'-VV J, 0>U2_^'>^
X^rc^^ycxcLiA^ '.!A
' Xildress
^l
DIRATION
f Signed)
Mouths
6j . Vl)A.v^/v>-^.'^.^^^X\.
Pavs
I lours
M.D.
\ddross) C)xxLuwiX/> LCtv^ V'QwV
Special information onlv for Hospitals, lnstifufion< Transients,
or Recent Residents, and persons dying away from fiome.
Former or
L'sual Residence
Wfien was disease contracted,
If not at place of death ?
Ifow lonq at
Plare of Deafli ?
Days
IM \CK OI- nrKIAI. «)K K1:M<>VAI. OAIKo! IHioai. OI KKMOVAl,
rNI)i;KTAKKR
Ad'h i'<~s
N. R.
^.veny Item oii infonmetion should be CHrefu.ly «upplie... A(iH hUouIcI be «totcd KXACTLY ^^S';:;^';;^^;";;''^
>tate CAUSE OF DEATH in plnin term,, that It may be properly classified. The Special In?ormat.on for p-r-
state ^Aust Of- UEA IH In pi
sons dyinft away from home should be feiven in every inHtance.
•4
o
â– il
â– P.
HI
S «
\\l
i . '
R^>
"* 'I
;;-ii
*
I
t i
I III I •
W
I
i
'
^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Boiir.lof Il-;i!lll- V .^<
? » O. T » ("^ .
Dcrc-D -rri tmr^u nc rPOTlCirATF pr>R I N^^TRlirTIONft
I)(t
fr /^y/r(i, \X^.x<Y-udi "XX J'^O'i
Ee^Lstered J\'^o,
1144
()^,^)-o.A^ JmA,>
Deputy Health Officer
No
DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco
Cevtificate of H)eatb
( la. S. StanDar? )
PLACE OF DEATH: — County of^O^^^^ JXxX/Yv<;:<'t4.ccCity o{^O^rr\j J AxX/yvca.a.cc
\.u/i
St.;
Dist.; bet*-
and
/ ir deaW occurs awVy from USUAL RES I DENCE give facts called for under 'special information' \
V, IF oiiATH occurred IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME «A-«-^
PERSONAL AND STATISTICAL PARTICULARS
COI.oK
L
\< w \ « u- i;ii-;i'ii
\' .1-;
VI.. nth)
XX
) rii I
1
lA-;////.'
5
/>,n:
SINi.I.lv MAKKlIvK.
WiDi A\'\'\\) OK I)IV()Kii:i)
'\\;;t' ill -ociril iKsij.Mi:tti<)ii)
itik rm'i.AOK
(St.'itt or C-iuntrv'l
on (S
NAMlv Ol-
J-atii!;r
nikiiii'i.ArK
<>l" lATHhK
(Slat' i.r t'omitry)
MMI>i:x NAMl'
<»1- MoTHlvR
nn< ^HI>I,A(•l••
'Slate or Country)
Ajuo
MEDICAL CERTIFICATE OF DEATH
DATK OV Dl.A'rii
a.
10 ipo'\
( Diiy) (Year)
(Month) ^
I ni'Kl'lHV ClvRTM'V, That I attcii<k'»l dcceascil from
1 90
to
TqO
T()0
tliat I last saw h • ^ alive 011
aiul that (loath (UXMirrcd, on the date statiMl above, at I
\J M. The CAISI': OV Dl-ATIl was as follows:
I)( RATION }'i'<irs M out In Days I /ours
(.'ONTRIIU'TORV
??
nr RATION
)\'ars
Mtntl/is
/hiv
^
A'N^O^
n
\J?X'
cu±.
"'ATl-A TioN
AAXXj
*• )V,/
^ lA'/z/Z/v / b />:â– ' ^
(SIGNED ) ^ -KJidjiKJi/di< U. ^'O^'YX. >\.-.M,
[Xu^<X ^3^ loo'l (A.l.lress)t£)C)b a^v.tUK ■nj
I lout s
M.D.
iPEC^IAL IN
t.
Special information only for Hnsplfdls, Institutions, frdnsients,
or Recent Residents, j^nd persons dvin'j awny fro.-n home.
Former or j^ ctn â– n\ { noH lonq ai
rd
Tin: M'.OVJ- ST\Ti: I) l'KKs,,)\ \|, 1' xKiiiM I, \K>^ A R J-; IRII- T" • 1' 1 1 1'.
"I'.sroi- MS- KNnW 1,1 l)(.l.; AND I!) , 1, 1 1". !•
'iifoiniatit \yj
cnAXjL WlA^nxx^,
V'Mioss V
.\^^^X^ ^
.AX^Li-
Dsual Residence
When was disease ronfrarted.
If not at place of death ?
n Pidce of Death?
II
Days
I'l.ACi-: <»i" nrKiAi.oR r i:Mit\- \i.
/\J fUxXx
190H
ini)i;rtaki:r
DAi'i; of MiKiAi. oi rI';mi)\ai.
/A.Mn-ss %W^ UOa^Ly at.
N- I'..— hvery Item otf 1nfo.„„.t1on should he carefully supplied. AdF. should be Htatcd KX4CTLY PHYSICIANS should
Mtatc CAlJSn OF DIZATH in plain terms, thnt it may be properly classified. The Special Informat.on for pT-
sons dyin^ away from home should be ftiven in every instance.
»'
I V f ;
■„ i
, I '
m
r
i»i
â– H '
I *! f^
T
W
RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
liontd
111,- !• No. IS -^•':i^^
v~; iKxr *. <)
I* ii«^rfiii«^^^ii^^t« «^
I
I i^
^^.
7.9 6>H
li^'gislcred J\^o,
1145
Deputy H?alth Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( "Q. S. Stanc»arC» )
PLACE OF DEATH: — County ofOcdA. 0;vxx^vcv<i(u.. City of ClCL'^nj v) A^CL-->vC'-^yC
N
0.1V
#
.LA.<iX
Dist.; bet
^
^
dj/YN/ UvOX-u and
v^ St,; t)
(IF DEATH OCCURS AWAY FROM USUAL RES
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREE
Oj^\
ROM USUAL RESIDENCE GIVE facts called for under special INFORMATION" \
TANDNUMBER. /
FULL NAME
cc/vxc
>vcl
cnaju,{.
k
PERSONAL AND STATISTICAL PARTICULARS
si:\'
i).\ I
ACK
COI.OR N n
Kill
M.mthl
lb
Dtv)
'Vtar)
I 5 )>,;;
1 /,.»////>
5-
/.'./
' -it'iKiliuii)
I'.IK THl'I.AO-:
'St.it. or Contilrx'
V\M1 III
1- '.ill i-.k
lUK rin-i. ACK
<"" lATHKR
tst.itc Jir C(»\iiitrv
O! MOTHKK
H!KTin'I,\fl.-
OF \5(iTllKK
'St;it( ur (.â– <.niitr\
MEDICAL CERTIFICATE OF DEATH
DA TK ()!• DKATH Pj
LUXCL ^i
(Month) /|
1 Hl':i< !':i5\' CI-RTIl-N'. Th;it I ;itt(.'n<U(i <kHcasf(l fn.m
(Day) (Year)
tliat I last si'iw h '.. alive on iJ^A^vCy V.O up H
and that death orcurreil, on the .lali- ^tati<l jihovo, at W
wL M. The CAlSf- OI" l)i: ATll was as follows:
DlkATION >V(;/-i -Months b /;«[)'.? Uvur^
LoJU
f^fsitifif ill San f'l aiirisro 5>« 0 ) ' '"
-'AJAj^'vVJl
SI QA.^^
CONTRIIU'TORV K,^(y^^OJU^X^^.<r>^ Cjjf
' V 'V
DTRATIOX )Vr7/-5 ^f,))ll/ls /)(7ys Ilour^
(Signed) Vj- >. LcrAv\..o^.v' M.D.
(jL^o 'rATooH %A.i.ireso io^sVinn.ojJut cit
:a
Special Information «nlv tor Hospitals, Instilulions, Fransienls,
or Recent Residents, and persons dying away fron home.
1/..-////-
I hi \
111 Miovj.- sr \ri-. !) i-KksoNAi, I'Ak ^h■^•,\K-^ aki: rkii-; lo 'iiD':
Hi;ST OI- MV KNi)\VI,!;i)(,K AM) lU-.I.I l". l-"
'I'lfi'-mrnit
(AcldresH
Former or
Usual Residence
When was disease contracted,
II not at place of death ?
How lonq at
Place of Death ?
Davs
,,, ye,.- ,,, i-i KIM ok ki;Mo\ \|, I l)\'li;of UiHiAi. or KKMoV.M,
INDLRTAKJ-.K
.,,i.,. ibi 0>u.-
,<iuA V C-^^
N. \\.
â– Kvcry 1,.n. oV infornu.tion should b. o.rcrully supplied. ACJf: .h.u.UI he Htated nXACTLY PHYSICIANS nhould
Mate CAlJSi: OP DIIATH 5„ pl,.!n terms, thnt It m»> be properly J»««ir.cd. The Special Information for pT-
Btaie ^,M.j.>|: |»|- Ul A I H in pi
«on« dyinj^ uwny from home Hhould be feiven in every instnnce.
111
f !
V ».
f .
M'
)
vt
f
II
I.
â–º'V
1' iil
» .
1
Wl' I
I, V
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECqpD
}!o:
:il(l of Ht*!lllli I >" • "••.-^-v*
«,^P.,.n -..^ na^LT /N E> /^ C B-T I P I r> AT P m R I N CSTP I I TTI O N ft
Be^isfcrcd Xo.
i146
luilr FiU'il, \k^.^.o.AAAJJ XX I'^O'i
DEPARTMENT OFPUBLIC HEALTH==City and County of San Francisco
Ccvtificate of Death
( "Cl. S. StanDarC^ )
X %
PLACE OF DEATH: — County
of CJOL^A; 0 A/CLA^C^U^C^cCity of U/CX/^OJ 0 AXX.
St.; 1 Dist.;bet. cLcx^^tv\.'.\
and
(
,. DEATH OCCURS AWAY r^' O M USUAL R E S I D E N C E G . V E TACTS CAL.ED ;0" ^^N^" J " ^j^.^D ^N U M ^E r"
IF DEATH OCCURRED I 1^ A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER.
N.)
FULL NAME
(^
â– ^
0-trVX
PERSONAL AND STATISTICAL PARTICULARS
I COI.oK
A.
u
'II
(ly^
\> : !
^ Jilr
M..nth'
3vX )-.,:> lo
lb
( I):iv)
A /.>„///
IVvnr)
/),M.v
-. •.,,;. MAkKn;i).
WIDOWKI) (»K DIVOKrivl)
â– :i ^' " i.-i! il'^i V II, it inll )
iiik ! tii'i.AiM-;
'Sttitf (If t"i)initl N*
\\M) ol-
' i II ru
I'.IK 1 III'l.Ai'K
MAII)1;n XAMi-
Ol- M()Tni:K
HlkTIIlM.ACl-;
;>!• M<tTMi:R
\ 1 It iX
O'U-
(Year)
MEDICAL CERTIFICATE OF DEATH
DATl-: (>»• Dl'.ATH O
vXu^a ^^
(Month) K 'I>'»y^
I IIICRMHV CI'RTII'N', Tliat I atk-iKlcMl .Iccc-ased from
xYVuxA^ 190H to IW^OL '^^ ifp "^
that I last saw lit >. alive on U-Vv.<ai 'kb Tip '\
and that <k-ath orcurrcil, on tlu' .latr statd al.ovf, at vu
(j M. TIk- CAl Siv Ol" l)i:.\rii was as follows:
nr RAT ION ^ )V</;--?
CONTKM'.r'roKV
MoHlhs
Dav^i
J /outs
DIRATION
(SIG
)'t iirs
M,t>it/is
NED) d. UJ. ^ C^^^CX.^
/></!â–
h'f^ldf.i in S\ni /'mill />■>! ol'X 5 ■-•<;( - V \h,iith< O /^'/
Tin M',M\-I.: ST \II-I» I'KRSOX \|. l'M<IICri. \KS AKi: TK! J-: To THl",
i!i:^r oi Mv KN(»\vij;i)<-,i<; and I!i:m)".i"
vAJ aJLLv/CC/>\v
' \.l<lrr^^
I'iQsO Vl) ,\>CKVcb-v<XA|
\+
XI Tc)o'l (.\.Mrrss) I'X^H Vb..VHX^N^M:'.<-^ "^'^
(^
I lours
M.D.
^-
SPEClivL Information on'y f<»r Hospitals, institutions, Transients,
or Recent Residents, and persons dvin'i dwdy from home.
Former or
Usual Residence
When was disease contracted,
II not at place of death ?
How long at
Place of Death ?
. Days
PLACK Ol" lURIAI, (»k K1;M<»\ A!.
iiAn;'.; ip ioai. oi ki;m«>\ai.
Ov?) T90H
r.NDl
N. P.. H
.. . Ktr. »i,r...l.l ha Ktnte«l fiXACTLY. PHYSICIANS Hhould
.very Item of Information «houl.l b. cnrcfully suppi.ed. A^•^:;^"•'„''^^^^,.:i"*^;he. "Special Informnf.on" for p^r-
Htnte CAlJSf: Ol- DLA TH in pluin terms, that it m»> be properly cIoshi^icU. me pa
"on* clyinft away from home shoiiltl be aiven in Q\firy instnncc.
i
»â–
fi'
41
1 »
Up
! '^ '
^ < .
\ .1
«â–
t .
i!
!i ii
ir^opr
i. ±
I
li ill
M i
II
T,\
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Board
i; vn. ic t^-5-'3r:-:5t4, \\^\' C
REFER TO BACK OF CERTIFICATE FOR I NSTRUCTfONS
J)(lh /'V/r^/, IXxAyOLAAAA; X\
If) a
lie<^islcre<l J^'^o.
114^
\y\ji
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Cevtificate of Beatb
{ xa. S. Stan^arC» )
PLACE OF DEATH: — County of 0 XX^X) 0 .>v<X/-yX/CA^coCity ofO^X^^^ O.^O^o^c^^^^o
^
.1^.. let J^
...1. 4-
CHU\.v^V,CL.\.) St.;
Dist.; bet.
and
-)
^ f \T DEATH occursAawav f r o n* USUAL RESIDENCE Give facts called for under "special information" \
\] V IF DTATH OCriiUiRFr. in a HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME
cUUrr^CAXX; vJ y«^OLAlLtrVcx.'
si:\
PERSONAL AND STATISTICAL PARTICULARS
I CDI.OR
,kXjl
'!• UIRl'll
Moiith'l
A ( , 1 :
?.
) I a I
W
I Day)
M. ,„!>,•
r %1 0
(V<-iii)
/'(M
'^iNi.i.i': M\kkn-:i>.
"i.'il (ksi^Mialioii)
HIK riM'I.AOK
(Strife or riMiiitrv^
i- NTH i:k
niKiniM.ArK
'>'•■I AIHI-.K
'Siat( ci r.nintrv)
a/vxxyU.
MAIDl'N NAM J.;
''iRrni'i.Ai-i.:
<»!• MnTllHK
(St;itr .,r r.iuiitiv )
(^
JL\X-^Oo
?
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATH r\
ULu^/Q
(Month) A
I H1{R1{HV CI'IRTIFV, Tliat I .ilteiulcil dcooascd from
to LlxA/CL IS i<)oH
(Vfar)
Qs C) 1 90 H
that I last saw h-C .>v alive on
:^
^^p
ami that death occurred, on the date '^tati-d above, at o \o
A1 M. The CAlSlv Ol" DliATil was as follows:
^'
m' RAT ION
)'riirs
Moullis
/)avs
J/oit) s
CON T R ir> U T ( ) R \' O /0_'>^.-O/U.^v^-^ ^- A^^Jl. . A^»./vvq^.
f\^sidr,1 1)1 Suit Fiaiiristo " )V-mv jL M.^nth-
nr RATION A~J'''''x.v
(op
( SIGNED ) 0
^rolll/ls
/hiVS
r
go TQOH (Ad.lress)
Special information ""'> '"^ HHspltdls, institutions, Transients,
nr Recent Residents, and persons dying away from home.
y^ Co lo O^^vt
/fours
M.D.
Former or
Usual Residence
vj(yvu<.UL at
^ I ^ Vj (yv»>JL
HoH lonq at ^
Place of Death? VI Days
/ '(/ 1 >
fii
lIi; \U()\-]; sTAI'i:n rKK^ONAI, I'AR I'nri.ARS AR1-; TRrH To 111)-;
lilvST 01-* MV KNOW 1,1: DC K AND IU:I,I1:f*
ll
rvdclrcss
-ii-^-^AjU,!^
^^ \J0 . (AO Cs^Vwi^-OyX
When was disease contracted,
If not at place of death?
ri \ri-: ol- lURIAI. OR RI'MoVA!
rNDJ-.KTAKKK aJUL. ^ (ib <Xxya, w
(Addrc-.s Sio^'a- \^LL C3t
DAri:<)! ItriMAi. or KHMO\AI,
T90H
Ion should be cnrefu.Lv supplied. MIP. should be stated F.XACTLY PHYSICIANS should
'H In plnin terms, that it may be properly classified. The "Spec.al Inform»t,on for p.r-
'^' ^- r.very item of informnt
stnte CAUSE OF DEAT
sons dyin^ away from home should be jiiven in every instnnce
%
i i
'I t .
• <
* <\
i
Mh.
i "< â– :
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Bo:i
:,r,lof llc:.llli- !• N<>. i^ 1^'^^s:^- WScV C<
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
^ I'
!
*
\
•; 4.
!)(//<â– Fi/('f/,
ck.^r^-^-'^^
"XX.
190\
llogLslcred JS'^o,
J H 48
Deputj/ Hea^^^^^^ Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( Xl. S. StnnOar^ )
J? (3ji i ^
PLACE OF DEATH: — County
Noilvd
mUoa.
(MP
\y>\JL 0
DiH-
xCl,'
a.1^ St.;
Dist.; bet/
and
/ IF DEATH OCCURS AWAY FRdM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
\ IF DCATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
kA. J /CLci/'vCr\'
PERSONAL AND STATISTICAL PARTICULARS
^i:\ A _ A I coi.oR
XjaxjJjl
\i\ .1. \)V I'.IK Til
A(>i.;
n
'Dav)
Alt
(Vt-ar)
4
medicAl certificate of death
date of dkatii
I Day)
(Month) ,
)
/QO \
(Year)
::)x \ )V,/;.
.M..>it/i.-
'\
I\i\:
"^IN'.UK. MARUn:D.
W IDttUKD Ok DIVOKTl-.D
' W'l ;(â– ill siK'ial <lt -ij.'iiat i' >n )
I i
I
I' r
'^tate riT Comitrv)
N \MI' (>!
1 \tiii;k
''â– IkTil I'LACl-:
'•I' I A I' 111' R
'Stall or Coinitrv
MMIM'.X XAMl-
<"â– M')Tm:k
•'■"M'm'I.ACK
'•I' M(iTin:R
(StatM or (.Viuntrv)
•>* 'II'ATIOX 0
fyrsidrtf in SiUi /'> a)i, ?-,ui O )'rtns *" }f>')illf~ ' /hi\^
■I'M)- \!u»vi-: SI' ATl'I) I'KR^oXAl. I'A R I' U' T I. A R> ARl'. TRrK To I'll)-;
lU'.ST OI' MV KNOWIJ-.pCK AND HKUI1-:f<-
I I11':R1':BV CI;RT1I'\', Tlial I alteiKKMl (U-ccasfd froiii
kwLu SLA i(,oH to LLvA^ ai iqo H
â– 1 ^ (1 ^ '1 ,
tliat I last '^aw li wv^xalivf (Ml VAa-a.^ X^ np 1
0 n IT
ami that (U-atli occurred, on the ilale stated above, at <K- 13
\X ^^. The CAlSlv OI" I)i:.\TH was as follows:
TM'RATION )V(//-.<r I Mouths Days I/ours
CONTRIBUTORY
DTRATION
}lciirs
Months
/\i\'s-
//ours
M.D.
(Signed) LU. U ux»^'vvx.lv<i.ti-.v,'
Address)\J 'UXA.^-^^^^ ()bo-^}\AXai
2>.l ino'A (
/VQ_-Cl >x^
'I"f"mant UJ . ^ . d iA.^'VVAJ'^
Special Information onU tor Hospitals, institutions, Iransienls,
or Recent Residents, and persons dying away from home.
Former or i^ n t(^^'^ \ ""'' '"?^^' . ,
Usual Residence ^ o o N.iUyw>vo. )i pi^re of Deatli?
Wlien was disease contracted,
If not at place of deatti?
Days
iMjiCi: OI- niR^Ai. OR ri:m'-\ai.
1
DAXJvof IUhiai, or KHNJo\Al,
Q.^ 190 l
N D 1 ; r t \ K i •: rM ^ J CUi<Lt/w H iV Vjj XJLOAjku K J
KXXrsx.
N. B.
â– Hvepy item of InformntJon nhoulcl be carefully supplied. M.V. nh-n.!.. be stated RXACTLY PHYSICIANS should
«tnte CAUSE OF DEATH in plain terms, that it may be properly clH^sif.cd. The Specol InVor.nat.on for pT-
â–
'ri
.r^
._ i
. ♦
i: -I
it
i
» ' I
sons dyin^ away from home should be ftiven in every instance.
ir 1 .' i
I
w
? â–
m
^n
WRITE PLAINLY WITH UNFADING INK
1 f II, 1 1th 1' Vo : ;'?•."■. ^3:"">i~> Hit 1' i"<)
THrS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/v/^v/, (XwQA,^^ XX 100 H
Ecg/sfrred jYo.
1149
â– L_
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Cevtiftcate of Bcatb
( XX, S. StanDarC> )
J? Op i %
PLACE OF DEATH: — County ofCJCL^>a' J A.Cu'va.cc^ ccCity of U/CLA^ vJ^\XXA^^^4.e,o
JX.\j^^ St.;
Dist.; bet.
and
/ \F DtATH OCCURS AwAv FROM USUAL *^ E S I D E N C E GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
V IF DEATH OCCURRED IN A HOSPITALER INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
-^l \
I' \ 1 i "I IliU TM
COI.OK
Q?
J JLAT
I Moiilli)
t-vj ,-
A^
\i .!•.
'-IN'. 1. 1'. %;akrii;i).
WIl»i )\\ J.-.I) OK I)I\'( >KC)-:i)
'\\' ' 111 socinl flfsi>.Mi;it ion )
HIK IIII'I.AOK
(State i>r Cuiinti v)
L
1 /."////<
n
(Wnv)
Ihn.
'â– \TI1 l,K
HIKTIIl'I.ArK
OI- i'\rin-;u
IStat*' or f<)\iiiti\-)
<H- MornKR
'ilKTMl'l.Ari-'
'>'• Mnrin.:K'
(St:itr ill roiiutrv^
MEDICAL CERTIFICATE OF DEATH
a
Months
3.0 IQo''\
(Day) (Vfiirt
I H1";RI:HV CI'RTII'N'^ That I atUMKlod <lcocasetl from
190 to 190
tliat I last saw h â– ali\i- on up
an<l that death occurred, uii the date stated ahove, at ^
M. The CAT SI-: OF DliATII was as follows:
)F |)1;A ill was as loll
DTK AT ION }'ta/s Mouths Pays J/onrs
CONTRIIU'TORV
1)1' RAT ION' )'iiJrs
Mo)it/is /^avs
(Signed) OAJ^cLiLvx^A ^ Low'>%^-y%Ui.
^l ic)oH (Address) ioOb Q.U^l^A; nj
/fours
M.D.
'>'-'<'ri'\Ti()N
-?
/\fs/'ifr<f ill Still /'t (tin i\/-t)^
Ay^VOL'
II )Vnis -
iam////,
/>,M>
I'm, xHovr: stati-i) i-kksonai, i'aki'uti.aks aki-; rK\}", ri> rn)".
iM.sr o).- M\' Kx* i\\ i,i:i)c, K AM) Mj;i.n:i"
(Inf,,
niant
^ry\j
Special Information ""'y f"r Hospitals, institutions, Transients,
or Rpcpnt Residents, dnd persons dying anay from home.
Former or r,r,\\\ l) (? P ^^^ '""'' ''' a
Usual Residence i^o UJ<X;A.'^X\JLu^ A' Plare of Deaffi ? o Days
When was disease rontrarted.
If not at place of death ?
ra
r^
?
I'l.ACK Ol- lUKIAI, OK ki:M<»\Al,
DA'n-; o!' MiKiAl. or ki-:m<)\ai,
LIaa^q %'X T90H
^AAyW-
rAdih'-.'^
N. B— l.very item of inf<>rm..ti„n .houl.l h. c.refully Hupplie.l. M.V, Hh..ul.l be Htated EXACTLY PHYSICIANS Khould
state CAlISr OP DI:ATH in plain t.rmH, that it may he properly cl«H«iflcd. The Spec.nl Information for p^r-
Rons dyin^ away from home should be ftivcn in every instance.
i
^.'A
\ â–
I
t »;
I
[>«,;
!|'
!»!
'Jill t
f
WRITE PLAINLY WtTH UNFADING INK — THIS IS A PERMANENT RECORD
H<
,„,i,..i!, ,uh i-vo. ,,-»-y^gr^-^n&i-Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
a3>
lOCi
Registered »A7;.
1 1 50
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( H. S. Stanc^arO )
PLACE OF DEATH; — County of C'OL/^r^ 0 Axx/>-^yCvxi.^oCity ofO/Oyrv 0 XCUYV^av,^ ri.<.
m \'\\^ \x]J^'
SXa ^ Dist.; bet.
UDENCEgive facts calle
H OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME I
and M.UyaJ-
/ IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UND^R •'SPECIAL INFORMATION" \
V. IF DEATH "^/-i.oorr, im « UORPITAL OR INSTITUTION GIVE ITS NAME INSTEAD ^F STREET AND NUMBER. /
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
-x\jl.k:
A.
V
vd
J.
H â–
ra
•L
COI.OR
I'.IKIH
.1 Lt
xUJl
\'
IS
)'/•(/)
IC)
U
(D.tv)
M.'>illi>
(Year)
0
na\
â– ^ :.i M\KRii;i).
Willi >\V}-,I) OK DIVnKCKI)
luk riU'i.AOK
(St.'itf i)r Country
A.tX<^Vvr
NAMi; OF
J-ATin-R
(^'' I AlIIKR
iSt;itf .ir Cnniitrv
MAll)i;\ NAM}.-
Ol' MOT I IKK
IHRTHPl.Ail-
oi- mothi:r
(Stale or r<iuiitivi
\
MEDICAL CERTIFICATE OF DEATH
DATH oi- i)i:aiii ,0
(Month) \ I Day)
I HI'IKI-HV CI-RTli'V, Tliat I .ittL'ndc.l -Ictx-ascd from
!l iqoM to Ia^VXX. X\ 1(>oH
tlKit T last saw h v.."- alive on LA^AA-Q^ '.•-! \<p' â–
and that «U'ath occurred, on tlie date stated aliove, at 1 J. 1 0
J M. The CAl'Sl-: Ol- Dl'ATfl was as follows:
Di; RAT ION
^ ]\'ars ^ Mouths
CONTRIHl'Tf^RV UXaJLa^ VI TLL . , '
Hays
Hours
Pays
Dr RAT ION n^ '"'/>> 'â– 'A'^/M.s
(Signed) G. "o. ^.ka^'' -â–
Addivss) lUoOa^vMl
^ V O-
OCCrPATlON
^''â– ^nf/-,i ill SiDi /'i,iihiu-,t OU )V,Mv - M'tiflr
/',
THI-: ahovk staii-.d ckksowi, i'\k m^ri, ars art. iKrK to thk
in:sr o).- mv knowij-.dc k and inci.iiu-
(liifoiinanl
%'\. iqo'l
{.
i<L^
M.D.
Special information onlv for Hospitals, Institutions, Transients,
or Recent Residents, and persons dyin^j anav from home.
Former or
Usual Residence
Wlien Has disease contracted,
If not at place of death ?
HoH lonq at
Place of Death ?
Oavs
DAT^')!" Mtkiai. or K1-;Mo\AI,
iu.acp: OF lu-RiAi. OK ki:mo\ai
TQO \
N. B.
F.very U.™ „f l„(,..,„„ion .h„ul.l 1,= ..,ref,.My .applied. AGP. «h„uUI be s.a.ed F.XACTLY , P"/*'*;'*!:'' "''""'t
Mate CAUSE OF DEATH in plain term,, thnt it m..y be properly clawiSied. The Sp.cal Informat.on for p.r-
sons dyinft away from home should be feiven in every instance.
f
!â– ;':
v\
I
i-
I
I
\m
u
ri<
II
11
m
I. i
K '
i-,>
4
in
[1
r
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
RoMPl..! II' :'"!'• ''^<^- ''
TV.t^Jr?S.;i lutr Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Diih' I'lleii, Clu..xy^,.v^ ^3 /'"^^H
Registered jYo,
1151
i
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTIi=City and County of San Francisco
PLACE OF DEATH: — County ofUQyvu'J
Ccvtificate of Bcatb
on J (^
AXX/waA^<LC^ City of O'CL-v^ 0 A^O^/wCa-A-C-O
.;>
N<>
Vx >\t^
-V
A^^JlXOUL^v CM ti VD Cs4 K V. '^Sm '
Dist.; bet.
and
f ,F DE.TH OCCURsiVwAY FRoJil U S U A L ! R E S I D E N C E G . V E TACTS CALLED FOR UNDER 'SPECIAL INFORMATION" \
C IF DEATH OCCulfREO IN aOhOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
FULL NAME
SjxxXxXJ
X/lxxi UJx^X.-a.vA>iu.
ri)
K.f^.
PERSONAL AND STATISTICAL PARTICULARS
T> (\ . I COI.OR
i niuTn
^ '
V '
ll^i
S^
) :■„■<
M.mth-
( Veil I
/',/!
'^^ MAKKll-.I).
W Ii»" lU l-.I) OK I)IV<»Rv-J-:i)
(Wlit- ill v.,.i;il •lc>.i",r|l;,(i,,,l)
lUR'!"!! 1'! X,- ]•
•1 : \
''â– li â– ;i I'l, \rK
<M 1 \ !in-:K
'â– ' ' '"iiiintrv^
M Ml II. N NAM!'"
<»•• MOTIUIR
'iiKriii-i.AD-;
<>!' M»iTin<;K
'stall- iir Coimtrvl
K.^'\ V'
I Xhyv%^<x % "^ ^
>CrV<-^^A^
MEDICAL CERTIFICATE OF DEATH
D.ATK OI" DKA in
3.1
iM()iitli>
(Vc:ii)
I liliRl'iHV Cl-;RTn'''V, 'riiat I atlciuUMl dcn-ascd fmiii
— 1(^0 to ~ U)0
tliMl I last saw h ~ alive on ~~ I90
ami that (loath occurred, tni the dati' >^tated above, at
M. The CAl'SI-: OH I) l". .XT II \va< as follows:
Drk.xriON Yeats
CONTRir.rTORV
Months
Pays
Hours
M
' H (T I
h\-udfi'. ill San I- ttiii isrit W )V(// >
lA nth-
/':.M
Tm-; MiovK sTAri:i) {'Hrsonai, PAuruThAKs aki'. vkvv. to Tin-
lU.sT OJ- MV KNo\VI,i:i)C,K AND lU:!,!!'. I'"
nrRATloN Viars Mouths Pays Hours
(Signed) LcrVcrrui\; J. mD. LL^^^^^a^^ M.D.
ao
i^
-i T()o'a f
.X.Mresv.) L
.ft^l^rwlA^ W-VV^-^.-l
SPECIAL Information "nly lor Hospltdls, Institutiyin, Transients,
or Recent Residents, dnd persons dving Hway (rom home.
How long at
tsudl Residence^ ^ ^^ L<xLfc-\\\Ou Cjl- Place of Death? 1 â– - "^ Days
When was disease contracted,
If not at place of deatli ?
ruACic <>i- luKiAi^oK ki;mo\ai
I) \ 11: ')t Hi 10. A I. .>! ki;m< »\ai,
(J.AAX1 ^H T90 1
N. B.
■1 %rK «hr...lil he stiite.l F.X4CTLY. PHYSICIANS Hhould
.very item «f information .houhl be o.refally supplied. 'y'flj^^^/;'^^^.^,.^" / * ^he "Special InformHtion" for p-r-
tate CAUSE OF DEATH in pinin terms, that it may be properly wlaHsi»ic<i. 1 ne o,
sons dylnft away from home should be feiven in every instance.
1 f
• A. A
ll'fl
\^
I
'. ! .
♦ \
' »t i
I.
\\i
>1
! »
1-1
«<
hi
^««^-
'- %,.
1 ^ ^^
hi
i-i
!
,1
f
III
fir
^k
: I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Boanl -if II
,!t!i I- No iv "^"'S^r^' '''^'' ^'"
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
J)a/i' riJrdy CL^xyuuit X2> I'^O'i
Deputy He^'th r\^i^x>
Bei^isfci'cd J\'*o.
1 1 5J^
DtPARTMENT ()F PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( XI. S. Stan^ar^ )
N
J? QT) A (^
PLACE OF DEATH: — County of OcL/^v 0,^^XXAa<i^ULCo City of O/ClavO Axu>v.c\.A/oo
o. 'ISi CW>XxLl/>a; LLx^-e^ St.; R Dist.;bet.JA.O^->vkX<^V) and U^tCOyf-^
/ IF DEATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ A
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / J
FULL NAME
.KJXj^^'s^'Oj Lc I l â– .
PERSONAL AND STATISTICAL PARTICULARS
m:\ a a ^ ! coi.oR
WA ; > â– ! r.iRTii
N 5
\~:V
' Moiithl
(Year)
A(,]
41 ,..„,
A M.nilh^ Jv I
Am
^IN'.l.r.. MAKRIl-:i).
WIDoWKI) OK DIVOKri:!)
' ^^ â– â– ' ' â– ' li "-ii'iiatioiit
IWk 1 ill'i.ACK
(State or Coiintrv^
NAMl- <il
fatiii:r
iiik I'lilM. ATK
â– "' ' â– ^''>iintrv'
MAII»}.;.\ NAMH
<>'•■MOTHKR
<>1- MoTlIKR
(Stati- Mr Coiuiti vt
'" ^"t I'AI'IDN
VA
NXAyvo
OL
OJ\AyO^A^
\
MEDICAL CERTIFICATE OF DEATH
DATl-: ol' Dl'.ATH
(Day) (Year)
(Month) .j
I UI{R1;BV (.■I". RTI !• V, Tluit I attc-iKkil tlcorased from
to LAa-^-Q "^^
up H
M v^^
-^
that"! last saw li ••^' J alive 1)11 LLv-VO^: >. 7(p
and tliat duath occurred, 011 the date stated aliove. at I
CX :M. The CAISI' Ol' DI-ATII \va>^ as follows:
DC RATION ^ )\ars A/oni/is /hus J/oiiPS
C ( L\ ']• R I I'd ' T 0 R \' LclAxL^<X^ dJXO^'X,^^
'^v_Ow.>vA^.y:v.
or RATION ^ )'<â– <//-.? Months Pays: //dius-
(Signed) \. 3 cr(>-cr^^- 'v. - M.D.
Special information onl> t'"^ Hospitdls, institutions, Fransients,
or Recent Residents, dnd persons dying dHdv from liome.
(y^Ji/y\j Kj Mx.y^vw/Q^'^^A
I
f\fM'(irtf III \,i)i I'l ail, isi'o f<0 )Vr//y *" M,<iilli<
/'(/)
I'm; AH')\-i'. ST \ri:i) i-kksonai. r\Ki-uMi,ARs ari-: trik to tid-:
''l-.sroi- Mv KNo\\I,i:i)(,H AM) HHI.n-F
Or
f'-:mant M iVv^ Q. ~0 ^\Xa\^kj^\^^ : \
\'l(lrt?ss
io'X'l "d\X>AJk./.rvx; ^i^
Former or
Usual Residence
Wtien was disease contracted,
If not at place of deatf) ?
How long at
Place ol Death ?
Days
I'l.ACK ni- lilRIAI, OR R1:Mo\AI,
DATl-'.ii! Hi KIAI. nr R}-;Mo\AI,
LIa/^ X^ I go's
rNDHRTAKl-R J Jkj?.'CV-cUrV X)-U-V.>VVCi
'A.li'.K sv
N. B.
-Kvery item o.' infor.nntlon «houlcl b. cnrefull.v supplied. A(1F. should be stntecl BXACTLY P'^YSIC.Ar^S Hhou.d
Htate CAUSE OF DEATH in plain terms, that !t may be properly classified. The Special In^ormat.on »or p.r-
Ron« dyinft away from home should be feiven in every instance.
»5
\ â–
J . 1
r
I
I ' •
\\\u
V.
ji'h'
â– ^â– v
'vHf ;:.\ •
i-t
I
ph
f £
ilil
ii
'n
'i ' I
\ :
t ,
r
'I
I
il! $
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
noanl I
f ikmHIi I-
V,v 1^ t-^^^sSv^: lutr C)
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
l)((h> hlli'tl y xXx^^-^YJ^J^ 'Xh.
100 \
BegLsfcj'Pcl J\'*o,
\ 1 53
^-JUV
:i
Deputy Health Officer
'^k).
DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( "U. S. Stanc>ar? )
PLACE OF DEATH: — County of C)/0L'"r\;v1/L€u^\CA_4^C.c City of 0 O^jyx, vJAXL/^\Ca^ ex
Dist.; bet.'
and
i^ VwAJ\a/Ymju u\JO-<L^\>^/ax\ ot.; i^ist.; oet. ana
/ ir DEATH OCCURS /IWAY FROM JU S U A L RESIDENCE GIVE FACTS CALLED FOR UNDER "'SPECIAL INFORMATION" \
\ IF DEATH OCCUnhED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
â– -1.-.
ir
\' I
PERSONAL AND STATISTICAL PARTICULARS
COI.ok
V
XC'^
i;iK III
LL/yOk/y-
oXx.^
Muiitli)
0 J "/•<;»>
^1 â– ' ;.i' M.\i<kii-:i)
WIDOW HI) OK DlVoUrHI)
'^^ ' " ' ill ilf^i^'iiati'iii)
nik i in'i.Aoi-:
(state or Oniiiiti y)
N'AMI-. ()|.
I•■^TM|■.k
I'lK riiiM,\rK
'>'â– I \rin:k
IStal. -,i i-.,niitt v'
*>' MnTlii.;K
"IKlHPi.Ac,.-
<»!• MiiTin-.k'
'Stilt, or f,,Miiti\ )
> <;ir)
/></!.
^CA/W'^rvj
MEDICAL CERTIFICATE OF DEATH
(Month) ([ il)ay> (Yiai)
1 JIIvRI'iHV CIvRTII'N'. That I alteiKlfd (Icooascil frnm
\i 190 H to LLla^ OvCi i()oM
tlifit T last' saw h t , alive on LLmvX^ ,^L up H
atid that death occurred, on the date stated ahove. at V3 o C
O- M. The CAl SI- ()!• i)l';.\TII was as follows:
]'t'ars Mo)iths Ihiys I/oi(rs
) N T R 11 ') I "I' () R \' ^ -OJwOL^^-vaXi vJCi A^'vw'qM \.A.t !..< .
'" '1 |-\| IDX
cc ^^'d-^
AaxLoA-V U iXXj\^JL^
ex V V. L. ^
*3s.>cxXmAXA'
l\f~i,!r,f in Sun /'nniinrn ^0 )V,m>
1)1 'RAT ION - )('ars M. nit /is
fSlG
NED) J.Vr\. Jbouhjb
UajM3 :X?> iqoH (Address) U:1m '^-^
/hn
'A'
I lout <
M.D.
Special information <•"') ^'"' llospild^. institutions, Irdnsients,
or Recent Residents, dnd persons dvinij dHdv Iro.-n home.
Former or %-^ ^ '^^''^^ ""^ """V* ., '^^
B^JL.T.'v.QL.vvc. Plare of Death ? oo
J/Ck^w.^
l/-.y////>
/),/!.
I'A.Ari; oi- inKiAi. OK ki-:m«»\ai,
J
I Ml-, \i(ovi-. s'j- \ rr.i) i'KKS(t\Ai, r\R rut I, \Ks AK1-; iki}'; t«» tiU':
Ill-.M ((I MY KNOW l,l.:i)(,l.; AM) l!!'. !, Ii: I-"
N. B.~>Hvery item of informntJon should he cnrefully supplied. AdF. nhouhl be «t"t«^«;j^'^.^CT''.Y; PHYSICIANS ,
«t«te CAUSE OF DEATH in plain term«, thnt it m»y he properly claHHiHcd. The 8pec.nl In»orm«t.on to
sons dyin( awny from home Hhould he ftiven in every instance
IsudI Residence
When was disease contracted,
If not at place of death ?
Davs
DXI'lio! Hi \'.\.\\. or K1-;M()\'AI,
-V<^ "k\ T90M
rXiIdo'ss
^ioia- \'^
PHYSICIANS Hhould
r p«r-
» »
m
I •â–
» t
«
li!'
•I .
• }
j^W
â– IT
â– i- i
I.
!
f^-
^Cwâ„¢
i
i ■• >'
â– 4
I
I
i^
"â– * r-^!
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I!,,;iV.! .1 !I .':'ll
Jhffr FiJi'd ,
cL^Cr^.^*^^*^
^'â– ^^ Qjl
. ! K I' U
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
as
1V0\
Regi.slcrcd J\''<i.
1 154
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
PLACE OF DEATH: — County of
Certificate of Beatb
( XX. 5. StanDarD )
,.XX/W\JUcL<X' City of
VJt<Loo \^<XJ
Dist.; bet.
â– nnd
/ \r DEATH OCCURS AW*Y FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' '\
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
.Ly\! U /CX,UL<xa
^
J..-.,
PERSONAL AND STATISTICAL PARTICULARS
aXo
MEDICAL CERTIFICATE OF DEATH
n
'Month) X
5t
) I'd >
il)av>
1 /...////â–
f Vrar)
.'?
/'.; 1.
MAki<n-:ii.
W llM A 1,1) OK I>I\(iKt'Kn
niK 1 , ].
(Stall- or Country)
CU^V<i;
,u
]
Hlk liilM.AOH
f'.'- » APHKR
'>^t.il( or rumitrv
MAllii-.N NAMl--
'»'■MnTHKK
OI' MoTHICR
(St.'itr or Countrv)
^y\j U /O^ULoLCyvia-'u
(Month) 1
/go \
(V. Ml 1
fl)ay)
I H1':RI':HV CIvRTIF-V, That I att(.Mi(lo(l (lect-ascd from
up t(i -— — — — — — — icp
tlial I last saw h ":: alive on — — up -
aii.l that (K'alli occurred, on the dale state<l above, at —
M. The CArSF* OI" D I {A Til \va^ as follows:
>.Xa. covet
tojvxxo^\xtj
<X.vvcL
1)1 RATION Years
CONTRIl'.rTORV
}'(•(! rs
Months
Days
I /ours
dtratiox
(Signed) oL LL'. c;>Lv^cUK ^^ .
LLa^.. Ov^v loO^V (.\<l.lress) VX.UX>->vJ-d.O.' V ^A
Mouths Pays
,'!>
Hours
M.D.
Special information ""'y ^nr Hospitals, Institutions, Transients,
or Recent Residents, and persons dvlny away fro:n home.
h'r !,!,■,; in S,ii> /') il». />»■'
M.'iitli^
l\n
IHK MtovH STATI-.D PKKSONM. I'A KI'K-I- LA KS A K J". TKrK To THK
lU'si ()); >,y KNOW i,i:i)(ji.; \\n I'.i: i,ii:i"
Vi . "O <xXX.<XX)A\JJ\}
\.Mi, s..
^<:xJ\J
Julka
Former or
Usual Residence
When was disease rontrarted,
If not at plare of death ?
HoM lonq at
Plare of Death ?
. Days
I'LACK OI- m-RlAI, i)K I<1:M<i\AI.
J\,^<y^
DAi'i: o! liiKiAi. OI ki:m()\ai.
0.5
TQO
■inlo CAlISi: OP DEATH In plain .crn,s, that it m„> h. properly cla».i.-ied. The Special lnfor,n,.t,„„ for per-
son* dyln^ nway from home should be jtiven in every instnnce.
â– I
\iX'\
« I
; I
I
â– t
I
^ I
I <
♦ ,
'â– ' V
•w
i:i
•'i^^:
«^:
mmi^
v-«»^-«p*-
»
l"S
ill'
h
11
ilii.
^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
H-.i-
\i 1 r. !â– â– Nil
»'-*-:r>.
) ItN; 1' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Ro<ii,slci'C(i ^Vo,
i 1 55
Ihil, filed. (Xu^.A-cJ: 13 1'fO^
Ifrw^lt^wM Deputy Health Offic-
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
PLACE OF DEATH: — County
Certificate of IDeatb
( 11. S. StanDarD -
of CICC'^AJ JXCL/^XCc^CCCity of 0,<X-»V) 0 ^(XAx<t>.v<i. n c
No.
(
X^tVvCvc St.; S Dist.;bet.
__ . IIDE
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVt ITS NAME
^tw
and
s;L
IF DtATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' \
I INSTEAD OF STREET AND NUMBER. /
FULL NAME
VD <x\.\^ . O'vl o.A.v.e.N
si;\
DA 11
A(.l-
SIN'
\vi;
(\Vi
PERSONAL AND STATISTICAL PARTICULARS
KIK III
V\ \
/^'IS
Month)
?^l
) ra I >
^
(Day)
M.'uHi^
l\i\.
M \K k 11" 1),
I <>k i)i\'(»R>-}:r)
- H'ial lU'sijfiiiiti.di)
CJ^c^x/cyLil
niR rm'i.xoH
(St:it. ,ir I'oniitrv)
NAM I- «>}•• /T^
l-ATiii;R L
lilKrill'l, AClv
ft 1
MEDICAL CERTIFICATE OF DEATH
DA ri". '»1 Dl- AlH 1
i Month' A 'Day)
(Yfur)
! Hi:Ri:r.N' CI:RTII-*V. riial I nUoinUvl dciHasrd from
thai I last <a\v h v . alive on V.Lv,a.O 9^3
an.] that death ocrurred, mi tin- .laU' -^tati-ij above, at A- O 0
U M. The CAISI-: 01; l)i:.\TlI was as follows:
n
â– v^C
h 'TN
|x^U^
.C^_t
.}/on//is
• ^l
^Ji
;
o ,cx W^<^
'V lAlllKK
'St;it( ,,v I'otintrv'i
M\nii:\ NAM)--
o|- Morii^;K
"nMUPI.ACK
01 m()Thi:r
(Stale or Coiiiitrv)
occri'A riox Qr>
Dli; Ai"I()N r' )''Vr
coNTRi r.rr«)RV
I)rR.\TI(»N .^ )V</;i Mouths
/>(7r.
//ours
J . QVV\.'^ A
v/Ol^.V-
//ours
M.D.
Signed) J .AA^-cr>^v<x>3
Special Information <»"'> '"'^ Hnspitals, institutions, Transients,
or Rerent Residents, dnd persons dyinj .mnv [ro;ii fiome.
A'/' â– .!/â– ,! ill S',111 /^ ,;;/, / -rn
]>,;;
1 M,.,if/»- Xi /
A; I
I'HK AltOVK STA11-I) I'KKSONAI, J- A KT KT LA KS AKi: rKlK T* » I'lIK
J!)-,M' »)i.- Mv KN(»wi,i:i)(.K AND iu:un-:F
(liifo'iiiaiit
^ \ili'. rfss
Former or
L'sudI Residence
When Has disease rontracted.
If not at place of death ?
HoH long at
PIdi e of Death ?
. Days
VI \CH Ol- in KlAI, »>R K}:M<'VA!
1) \TV. (.! Hi KiAi. 01 Ki;Mi>\Al.
rNl)i;K TAKl'lK
fAdilress
Ol Ov\ T90H
N. B.
». . , ,..1,1 ArF ahnild bc stiitetl F.XAOTLY. PHYSICIANS nhould
-F>very item of m?orm«tion .hould be cnrefuMy supphed. ^*'^- f"\ '^'^^^^^^^^^^^^ T^^e "Special Infor,n..tion" for p-r-
state CAUSE OF DEATH in plain terms, that it mn> be properly cIn««iVietl. me op
sons dyinjt away from home should be feiven in e%ery mstance.
'k j^ :."vij
I
« â–
^
1
i!
if.
■■•■>
I
I
-lit
;r
4
I,
!ii"
>i
ifij:-!
i^A
w
RITE PLAINLY WITH UNFADING INK^*^THIS IS A PERMANENT RECORD
lin.i;.
, , , I. Vo. ! ^ 1*-?^w^J^ lK<v 1' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
])((!( Filed , \Xxj^jo^juO^
X^h
100\
Bogistci^ed Xo.
i 1 56
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( "a. 5. 5tnnC»arc> )
PLACE OF DEATH: — County of -
â– No. J \X<Ll>vyljlA.A./o^>-v db (yvl., W y. I ':^ . ' St.;
/ imOEATH OCCU
V IJlF DEATH OCCURRED I
City of
13 VK
V.1
Dist.; beU
â– ^nd*
/ IF^DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' \
V, IjlF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
0
FULL NAME
!'Y^.'^..\.X.A.
I0.uv4.
PERSONAL AND STATISTICAL PARTICULARS
si;\
\\oli
(:•>!,( Ik ^
I)A 1 i; Ml- ItlKTH
A<,1,
OS?
I
OxAr
iMDiith)
O 1 )•-■,/;>
I
(Day
M.,„lli'
rlk^'l
lt>
I V tat I
l\:\:
SINr.i J- MAKKn.:i).
WllH.W i-K OK I)IVuKri:i)
'Wiiti ill MK-iril (Ifsi^riialiiiii)
HIK 111!'!. \C\-.
(Stall <,r Coiititrvi
FATin-.R
"IRTlll'I.ArF
f>'" IAiin<:R
(Stat< or Cuuntrvl
MAini-.N NAM}--
• ii m.»tiii:r
'ilk rupi.ArH
<»l" Mni-UHR
(Stair or r<)\iiit!v
OCCn-Aiiox
MEDICAL CERTIFICATE OF DEATH
DAri-: <>i" i»i;ath |
LVA.V.C! lb zoo'
(Moiitli^ ! (n:iy) iVi-aii
I HIvFvI'ir.N' C'I;RTII'\', Tliat I aUc'ii(U-tl (ItHiasftl finm
— up to "■" i<)0
lliat I last saw li alive on Mp
and that death occurred, on the date stated above, at
M. The CAlSlv ()!• DIlATII was as follows:
,.<k.L
(>v vi Jka-^o- ^ct
DTK AT ION Vi-ars
CONTRird'roRV
I )r RAT ION Viiirs
Mouths
Pays
Hour
M()>ii/is /hiys //ours
x^^ M.D.
\.Xr^u-v-Nj
l\f'>iilf(! Ill Siiji /'i t! II, / 'I'lt I \ )'<iti
1/,./////.
/',,
'Hi XHOVK ST All- I) I'KRSONAl, PA RT IC f I, A R > ARl-. PRri- 1' • IHi;
•II.^T <)I- MY KNOW Li: 1)1 -.K AND UI'.Ml-.P
'Inf.. -1,1:1111
\iMic
..^^-UUAj
:)±
SIGNED ) Vj . H- ^^-^^^-^^^^^
\,l,lr(.<^) \jlX>^^ \L\,0'v«
/u.,^n [\.
Tc)n
(
4-
SPECIAL Information onU tor llospilnK, Instihiflons, Transients,
or Recent Residents, and persons d\inii dnny from home.
Former or
Lsudl Residence
Wfien was disease rontrarted.
II not at place of deatti ?
How lonq at
Place of Death ?
Odvs
I.ACl'! <>l' lURlAI.oR K1-;M<)\ \I, l»All',o: !!. lOAi. 01 R1:M<)\\I.
INDl.K'l'AKl-.R
(AiMrt-ss
N. B.
.1 %rH ».ho.ilcl he stilted F.X4CTLY. PHYSICIANS nhould
ntJon «houl.l be cnrefuMy suppf.e,! J^;^;^'^^^^'%uc -Speclnl In.'ormaf.on" fur p-r-
\TH in nhiin tcpm«. that it mny he prcpcrly ciassmcu. .
Kvery item ot' Inform
Htjitc CAUSE OF DEATH in p
sons dyinft away from home Khould be jj^iven in every instance.
' • r
â– ' } â–
r
in
! I
i*
1 .
4i i
P-'
1^!
n
i
I
\h
I
h
t t
â– i
1
\
i
't"
1
■■»
1 :
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
.„r,|M Il.:,l.h l-Vo. ..-^-r^^HScrc-
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Deputy Health Officer
Eeo^lsfered A^o.
1 1 57
DEPARTMENT 01^ PUBLIC HEALTH=City and County of San Francisco
Certificate of H)catb
( 11. 5. Stan^ar^ )
PLACE OF DEATH: — County of O cxx>^ J.\^<X/>^tiA.ar./City ofU/(Xyv\; JAxXvv<i^xj_>ci.c
\S)XAJ^I\J SU D'lsUhct (j/0.yy\AArY>^Jb and \l I W>vto^X«
(ir Ot»TH OCCURS AWAY TROM USUAL R E S I D E N C E G I V E FACTS CALLED TOR UNDER "SPECIAL INFORMATION • '\ \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
fjil
FULL NAME
rvo^^ou^i
PERSONAL AND STATISTICAL PARTICULARS
n \ . : ' 'I i;iK Til
LL>Ok/>^
"Month »
S C) JV.nv
I Day)
Mn,il>iy
(Vfiir
Iht 1 .
(T'tY
MEDICAL CERTIFICATE OF DEATH
DATH Ol- I)i:.\TH
n):.y)
(Month) 1
(Year)
.^s-OJ-^-^
I III'RI'HV ClvRTII'V, That I attt'>i(li<l ilcroased from
\'U/>\X 10 iqoH to LLla.Q ^0 Icp'-i
that 1 last saw liX... ahvf on VA^a. t!y .-.o k/d ^
aiijj that death occurred, on the dali- state<l al)c)ve, af 1 oO
. M. The CArSi' Ol" DIvATII was as follows:
A
X^-^-L\X3o
I OjlI
\JJ\^^ V , -...'rx;
DTK AT ION )V(/y.v Months Pays Hours
CONTKIIU'TOH
1)1" RAT [ON ^ Years
M,niilr
Day
Vj cs-'xtx^j
occrpATiox
h'fsiijfti ill S,!u /nun ism
(SIGNED) U). d.MK UrvAyvvJuU.
LL^q X^ iqo '\ ( Ad.lress) l0$ qA^^-^Uj-K) 'jl
cJal in
M.D.
SPECIAL INFORMATION "nlv tor Hospitals, Institutions, Transients,
or Recent Residents, and persons dyinq .inay from fiome.
) '/â– (//
- Mnitli-
I hl\.
'■id: \m<»\i.: ST at i: I) i-kksov \i, rxuiicii. \ks aki; I'Kri". i' • rii )■;
I'.i.sr Ol MY KN()ui,i:i)c,K AM) iu:i,n;i-
Former or
Usual Residence
When W3S disease contracted,
II not at place ol death ?
Hou lonq at
Place of Death ?
Davs
rij^XCH <»!•• H( KIAI. OK K J. .Mo\ A I.
b.^'
INDl
I)\l»: of IM RIAL or KKMOVAI,
Hvery item of inf.rmHtion should be cnrcfuMy supplie.l. ACIfi hHouIcI be Ht„te.l »iXACTLY P1IYSICIA>I8 «houlci
state CAUSE OF DIIATH in pinin terms, thnt it m;.y be properly classified. The .Spec.al InVormHt.on for p-r-
sons clyin^ awny from home should be iiiven in every instnnce.
j*^
t '
â– |
li
m
m
i
I •
l!>
iff
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
ihifr /v7r'j,..CU^aL^vA^ ^^ nJCi
Bogistej'cd J\^o.
1 i 58
Deputy He
er
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of ©eatb
( "U. S. StanC»arC> )
PLACE OF DEATH: — County ofv^'^CL'^x- J ;V>Cu'>XCAA.CyC City of vJCLAV 0.\XIy>xc^AC.c
No, liHlo
St.; ^ Dist.;bet. \^
CURS AW
OCCURRED IN A HOSPITAL OR INSTITUTION GIVE I
ind I?
/ \r DEATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER 'SPECIAL INFORMATION" \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
\JV/>^vJL4A3
SI'.X
DA I i < i| lilKTU
A'.K
PERSONAL AND STATISTICAL PARTICULARS
iMoiilli)
V) \ )>,/;> A
1\
iDav)
M. a, I lis Q. b
/ is c
fVcar)
Pa \:
: 1 MAkKIHI).
W !i). i\\ KI> OK DIVoRiKr)
'Wiili in -()ii;il (U-si^iKilioti)
I'.IKTHPI.ACK
(State or Couiitrv)
NAMi: OP
fatiii:r
I'-lKTllI'l.Ai'K
<»'■iATin.:R
'^'•'ti- or (■>)ii)itrv
MAMU'.N NAMI-
•" MOTHHK
'HR IHl'LACK
<>»• MnTUHR
(Stat.- or Countrv)
1
MEDICAL CERTIFICATE OF DEATH
DATK ol" IH-'.ATH
IDav)
(Year)
I IIi:Ri;r.V C1:RTII'^V, riiat I atten<U(l .Icivasol from
ULoun \^ i()0 H to LA.A>ca ^l * it)o S
lliat I last saw h .'- > alive on LO^-A-Q ^! T90 \
and that death occurred, on the date •-tated ahove. at -^
vA M. Tlie CAl'Slv Ol- Dl'.A'll! was as follows:
C/NA.
\\.<ruj-^v
OCCrPATlON
^a
KJLK^kj^^^'
Dr RAT ION IC) )\'ays
CONTRIIU'TOK
Months
Days
i\ Ovvoci.A-0 t4rA.^^LA^X/^ LL(r'\X
Hours
CLL
DIRATK/N
)'i'ars
Mouths 3l Pays
0X'Vc'j\-O
rm
J?
(SIGNED)
J-^-A.o gg^iooH (Addres.) qn^ LcC<iM dt
L Information onU lor Hospitals, In^itutlons,
Hours
M.D.
SPECIA
or Recent Residents, and persons dying anay from home.
h'e- ■!,!,•, I ill S(! >.' / I III
"y
1 1 : â– ,,) ,< v..
;. }',,/
M,;,fh<
/'.■•i
THl-: AHOVK STATl-n I'KRSONAI, I'A R TIC f I.A RS AKi: TRTK To IMl-:
HHST Di- Mv kno\vi,];i)(;k and i!i:i,n:F
(Info
rtnatjt
' X'Mrrvs
Former or
Usual Residence
When was disease contracted,
If not at place of dcaffi ?
How lonq at
PIdfe of Death?
Transients,
Days
I'LACH Ol- lURIAI. OR K).Mm\-AI,
fNDKRTAKKR fo - J • 3.>UoW ^VC
'Address I I'i'T Nj iLoC.A-'Mrvv Ot.
D\ri-: ot i!( ki \i. 01 ki-;Mi i\Ai.
N. B,
Rvcry Item of lnform„tion •hould be CBrefully supplied. AGB nhould be stated fiXACTLY PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly claHsilTied. The Spec.al Information for p-r-
staie UAUSt Uh Ut A I n in pi
son* dyin^ away from home should be jiiven in es^ery instance.
jTTT^
t
»
i »
'Itl-
' 1
!||i
' 1
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
,5,„,,I . !l.:,Hh-rKO. IS^C'ir^^nS^I^
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
11
1)^
»i
<:«lV.^r
])((/(' /'V/^'^/, aXa^axIa-a^ CL?i
IfJO\
Rp^isfci'rd J\^(),
\ 1 59
• » — ., <> jW
DEPARTMENT OF PUBLIC liEALTH=City and County of San Francisco
Ccvtificatc of IDcatb
n. S. Stan^arD )
PLACE OF DEATH: — County of
/CL'Tv JAyo^'>v^uixio City of ^' Oyv\; 0/v.o^>^c\.<i^<r,
L
^
No. i'^'X^
/VNA-tVO
St.;
. %
<r\,AA.^Ow and V' ^ '^
( IF DEATH OCCURS AW*V FROM USUAL R E S I D E N C E G I VE FACTS CALLED FOR UNci^R "SPECIAL INFORMATION" \
V IP DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD\5>F STREET AND NUMBER. /
Dist.; bet.
FULL NAME
M',\
I)\ M Ml ItlKI'II
At
PERSONAL AND STATISTICAL PARTICULARS
1 COI.oK
/>\.Ol."v
iMDiith) I
l«
(l):iv) (War)
(
â– J J4,Vi>
>I4 %
\ 4
r
J 'ra I
,1 A -»/,'//>
â– ^
/),/ V.
SINf.l.K. MARUIKn.
\vii)n\vi-;i) OK niV()Rk)-;i)
'N\;it' ill -ooial lUsij^tiatioii)
niR IFIIM.ACK
"^' • . .1 r<niiitrv^
lATiniR
I'lKTIII'I.ArK
Ol" 1 ArUHK
'Sl:it< or Countiv
M\Il»i:X NAM)-.
•»!' m<>i-iii;k
(State iir l".iniitr\
• K'crpA ^l(l^•
> \vx,^ JuLL^wOL/^fV;
MEDICAL CERTIFICATE OF DEATH
IIXTI". ol' i)i:atii
(Month) 'j
'I>av')
(Ycari
I III':KI{HV CI'RTII'V, That I ;ittt.n(K-(l (Icci'asL-d fn.tii
Uu.A^_ 'iH 190 H to y-^^ ^^'^ i^p'^
that I last saw lii-^v>. alive oil LL^^^n ^ ^v i(p'\
ami that ikath occiirrcil, 011 tlu- dali- stahMl above, at I'- 1 A
^ M. The CAISI-: Ol" DIlAI'll was as follows:
\w^Cr'V\/^J^A,^JL^.'^--<>--^'^^.
^\?UL.<Crrw.f.^. ^I'wQJLrv'WXli. ^
1)1' RATI ON ^''li''^ Mouths ^ /\iys Hours
e" 0 N T K 1 1 ! (' 'H) R \' d x^Jj- t^^A^t/O^
)V(//'.v Mi>>it/i
\» 11 (
rSlGNED)
UrRATION
/:>,7i
'V
//oil
IS
W<1
, w.«.,w^ „ ^^\^ M.D
Ll'^v-q 1? iQoM r\.l,lrcsO lObS" fcoA^vnxa.. .J4
:a.
Special information onlv tor Hospitdls, institutions, frdnsifnls,
or Recent Residents, and persons dvinij dwdv Ironi fiome.
f^/'''!iirif III '^'ii'i i 1 ,1 III i ^I'li
)V..'
^â– .Ht/l'
h.l\
I III \H(»VK ST \'n:i) I'KRSONAI, PAR Tim.ARS \R1. 1' R I }•".
in.sT Ol- MY K NOW 1,1; IX. 1% AM) J51:I.IJ:k
Td Tin-
'liii'i'inaiit
J\JULy^
A-^CX^'VA.
^\(l(l
revs
HX'X
v.JLAywoL^
'\^A.\ywAX. *.JX
Former or
Usual Residence
Wlien was disease contracted,
If not at place of deatli ?
Hew long at
Place of Death ?
Days
ri ACH oi- inKiAi, <iK Ki;.Mit\ \i, j nAii'.ui r.riuAi, 01 ki;m(»\a:.
J\.<y^
(Address.. "Ill \l VU.^^
N. R.
' 1
-Kvery Item of in?»rmHtlon «houIcl b. carefully supplied. ACK Hhould be Htnte.l EXACTLY PHYSICIANS Hhould
state CAUSE OF DEATH in plnin terms, tbnt it mny be properly cluH«ilfled. The Special InVonuHtion Vor per-
sons dyin^ away from home should be fciven in every instance.
i^
'â– \
1 .
I
'I
ir
rms-:
1,^' •
r
N
I'
IP
Ph
I!
I i
% -yi
t>l .
I«:
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
nn;i!.! .;' 11' :iMh- »" NO- 1 "^
*.!; -K^:2E^. n&i'Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Jhf/r FiJcd, [Xk^^^^o^^^^ X'h l'W\
Xc^^^cv^ \sLri^ Deputy Health Officer
Be^isterrd J\'*o.
11 GO
DEPARTMENT OF PUBLIC nEALTH=City and County of San Francisco
Certificate of IDeatb
tl. 5. StanOarC^
PLACE OF DEATH: — County ofUXXA^ OAXX.'A'v^\^ccCity of vJcu^O; OAXX^-^x/av^
, r^ <'
p^.
â– ^t-
DCMl
4\A.A,
<x.
St.; — Dist.; bet.
and
('
F deathAoccurs aw*y from usual residence give facts called for under special information
IF oe4th occurred in a hospital or institution give its name instead of street and number.
)
FULL NAME
A.'^VM
PERSONAL AND STATISTICAL PARTICULARS
j COI.OR >
•\
.oJ^
10
MEDICAL CERTIFICATE OF DEATH
i>\ it; ()I I)i; a III /
A A I (JO
DA . i 1 H l;!KriI
Ai.l.
VKjQsJX'
'Month)
1 "^ ):iu.-
5
);i\i
Mnitlr
/lb I
(Vear)
ll
lhl^
-K'i.'il tksiviiali'iii)
BlkTMlM.ArK
(Sf:,», ,>r rnuntiv^
\ WW ( ti--
^^â–
cL<r^-A>-^cL
'CX.-v^- ^
'OwVaAJLA^lXIA
'VX/A^A
HIRTHIM.ArK
Of l-ATHKK
fSt;(tef)r Country)
MAIDHX NAM)-:
'>!â– M()rm;K
(Month)
I'J
(Day)
'Ytar^
I HI;RI':1JV eM:RTll'V. ti .t r alton.Ud dc-rr.ist-d fn.ni
\Sj^kx\^ \'\ iQo'\ to vLvvq^ XV-v up H
n
that I la>t -^aw li - ' alive- on LA-Vv/O. X.'X up' .
ami tliat fh-ath <>criirrc<l, on llu- <lal«.' stated aliovt.-. at 1 1 60
M. Tlu- CAISF-; Ul" Dl.ATII was as follows:
DTRATION Years Mouths H /^n.v
CONTRIIH TORY LJkA.^tnrA-^/c. LLLllXrr^XS-
I lours
HIRTHPT^ACK
OF MnrnKR
(Stale or Conntrv')
'Y\J
KcrrATinx 0 .
h'f^iiJf.J J n Sii>i J iitiii;^i'i
nrRATioN
(SIG
Years
Mioiths
NED ) LL^JJkA^^•' J . \j K 0-'
/)<n'.s-
>^OCS./^'
't
IIOU) s
M.D.
t: VmIol\y ^'^M^A-
s, Institunons,
/'<?)
•II \hovi-: sTA'n; I) i-kksonai. r \k ruTLAks aki. ikik lo iiii-
1:HST OH MY KNoWIJ-.DCH AM) HIIMIIF
'Iiifi..,nrint
(Address V) (>Aw/>-^ VA.AyCjK/VV^-'Crvvxi^ V^CU\.
LvXJ -v': i«)oM (.-\<Mrc^^1
SPECIAL INFORMATION "nlv tor Hospital
or Recent Residents, dnd persons dvlny d^Hv froii home.
Former or n u n r 4 y A^ How lonq at ,
Isual Residence A " 0 - ^ \Jc^ CJX Plare ol Deatli ? ^
Wfien Has dise ise rontracted,
If not at pUeot death?
Iransients.
Ddvs
ri,ACK<»l Itl KIAI, <iK ki;mm\\i,
(Address
1) \ 1 1. of i;i 1.1 Ai. ..I K }.Mi tv \l.
OLv
a
^.OL "^- A. 1 90 \
F.very Item oV mformation shoul.l be cnret'ully supplied. AGK should be stnted F.XACTLY. PHYSICIANS should
Uate CAUSE OF DEATH In phim terms, that it m»y be properly claHsilfled. The * Special Intormation tor p«r-
N. B. F..
state v*AU»t Uh UtA I M m pi
son* dyin^ away ?rom home should be fciven in every instance.
r';
'II
Ll
Hi
m
! n
|i '!
|l
I .
.•(^iJMvt
irif
)â– ' '
i
\\
\n
ii
H
ii •
hi
I ;
I >
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Rnanl ' ( II' :iHli 1- V". i "s
t!-?^'^ar>^-, HM' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dffir /v7r^/, (Xcvxioc^ ^3> I^^O'i
X^rv^.^v^ blx/v-M. Deputy Health Officer
llegi,sler('(l J\^(),
1 iri
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( "U. S. Stan^ar^ j
PLACE OF DEATH: — County of C'/CXax^ 0/vCL/^Ayt^^^ooCity of O^cco^ J Axx/>^.A^v>(L^e.o
N. . V lIu. ^ ^Ka/\<Xu Ob CK-KvXolA St.; Dist.; bet. and
A ( ir DEATH OCCi/rS AWAY FtjlOM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
\J \ IF DEATH O^JCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME cU\aa.^
LooCajla.'
PERSONAL AND STATISTICAL PARTICULARS
I COI.OK
U)ixc'
1> \ i : n|- lilK ril
.\«'. }••
as
(Vf.'ir)
MEDICAL CERTIFICATE OF DEATH
DATl-: Ol" DllA'llI
CL.
fMoiitlil A
(I);iV>
/go \
(Year)
55
O ) 'i-ti I
10
}f.->!l/iy
Vy
/><n
^IN'". I.K. M\KUIi:i)
\VII)n',\i.-n (»K I)IVt)l-(i-HI)
JHKrupi.ArK
'Silt, ,,V (>,„,„Jp^.)
\'\M1 n).
niK riiri.Ai'K
mah»i;n XAMi--
'*ii<rinM.ACK
nt- MfiTHHK
(Slnt. .,, Coiiiilrvl
h'f'iilf:! iu San I'l ,i
I IinRI'BV CI'.RTII-V. Th.it I Mltt'U.lc.l .Icccascd fn.ni
LUwA^ n upH t() CAa^^. 2L1 ux)4
tliat T last saw h-.^»v alive mi U_a.a^q_ ,k\ up i
.iiiil tliat dcatli occurred, on ihv «lati- '^tatt-d alxivf, at ^X Ob
'v-A_ M The CArSI- ()!• DI'ATII was as follow*^
2
d^,<rv>
<X.^'
CONTRIIU'TOkV
Mouths
Hays
\ ) t'li I ••
\fn„tll^
l\l\
(Signed) J
AX
i\ r:
Mi)nths
r()o4 fAd.lrrss) U^Ui ^"^^
Pay
//oin s
//ours
M.D.
SPECIAL INFORMATION only for llbspitals, Institutions, Fransients,
or Recent Residents, and persons dying away from fiome.
L \i!nvi.:sTA'n:i) i-kk-^onai, 1'\r rirn.AKs AKi-: TKrK to Tin-
"•>i oi' ^.u- kn()\vij:i).-.h and hi:mi:i--
flnf,
i-iii
'"I Uivooc^. Nl. 0
(Add
ress
N. B.
Usual Residence HC)'iViDA^a<i>c^>o^
When was disease contracted,
If not at place of death?
\ , How long at
M -1 Place of Death? 211
Days
I'LACi: ()!• lUKIAI, OR kKMo\AI,
'Xx/w./'y\^^
rNDKRTAKKR
^Address
l>A'l'JKof liiKiAi, or R1-:M()VAI
IQOH
O^^xx. .
-Kvery Item of inform»tion should be corefuiiy supplied. A(;F. should be stated EXACTLY. PHYSICIANS should
«tnte CAUSE OF DEATH in plnin terms, that it m»y be properly classified. The "Special Information" for par-
sons dyin^ away from home should be jtiven in every instance.
'I
i< .
f ! • »
1/
; 1
5-w
)
r
i
h ;
f
* "^1
J i
f-.-
;:i I-
i: i
h :
III f
I
\i
i .
\\ I
' ¥\
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
jt,,:iv.l . t' I' I'f' >' '^â– '>
1 ;, l"«'-.^K"«ui) HSlF Co
ncrtn iv^ cj»*\rfr\ v^r «>»fcr»iiriv>««w. r>*t» ■(««i«iaiw'wii>^t««i«
J)f(/f' Fifed ,
\j^y<^
a?>
VJO\
RosHNfcvcd J^''o.
i m2
y^ Deputy Health Officer
DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco
'N(
Certificate of E)eatb
PLACE OF DEATH: — County ofO/CLoA; JyVccovcolcC City of 0/<X/"rv 0/UX.^xCA>a a<.
lO C^ U.-Lobtx^v . St.; X Dist.;bet. (XJl<X/v-VY>JJu^t5^^
/ IF DEATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORWATit N ' \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND N U M B E ^j /
'V^JLCi;
FULL NAME
d ^i IjMi'cAj \l IM \\ ''< d A.C4.£L ■» V
yOX
â– 4-
-l^TjT
■±
â– '" ^
PERSONAL AND STATISTICAL PARTICULARS
A I C()I,(»R
I'.iiv rii
^ ^
yKct
â– I
M..nthi k
a^ / ^t e H
}V</; *
(l)av^
^ 'â– >////'
( S'fiii
H
-TJ\.N
/•■*f*-^.
\y\\>i '\Vi;i) OK DIVnKrKI)
'**â– "â– â– â– â– i.il ilt^-iviiatinii)
HIK riilM.ArK
'St.it. i.r ri.miti \
\"\\T) Ml
1' A I II i:k
A
(^ (1
MEDICAL CERTIFICATE OF DEATH
DA ri-; <»i- DivAiii r>
iMotitlll A
I III-RI-l'.V CIvRTIFV, That I atten.lo.l <lc(vase(l from
(Day) (Year)
Qv^ T9o4
tf)
that I last saw h-r*-^ alive on vAxa^Q ^'6 t..^ l
OvSi IC)0 H
CC 'Xcj Tip ^[
ami that (kath occurred, on tlie date stated ahove, at C o C)
I
^l^I. The CATS I- Ol* 1)1{ATH was as follows
''•IKTlii'i, \cj,' A
'*' > Villi; K Oft \1
iS.t;itt' or Cunti v) W r\
M \!l>i;\ NAM}--
'•I M'TIIKK
'tiK riii'i.AeK
Ol- MoTilIvK
''"^tit.- or (.•uiuiti V
^'f iiffi/ lit Sati /;,;/;, />,â– ,!
DIRA'IION ]'t'(irs Months Days^ \'^- Hours
DIRATION
)'ca)S
r
V
Mi>ut/is /hrys
//oin s
M.D.
LACA.^ X?> T()o'( (Address) I 5 I QL U XXm^V|\jU^ LI. v â– .
SPEfelAL INFORMATION only for Hospifdis, Institutions, Transients,
or Recent Residents, dnd persons d>inij .may from fiome.
) V'(/ ,
M.'itlh^
n.i\
1 "''^';'>\ ». SIATi;!) l-HKs(t\Al, I'AK'ricn. AKS A K }•: TK
'il-.^l <»|. M\_KNnWl.};i>r,H AM) Hl-I.n-IF
0- O. VJ^JL^
vv. •i< » riiK
!'â– â– niiiit
vxJtA.'
' X'lchrss
I
\rK./ou\JkA!fc
Former or
Usual Residence
Wlien was disease contracted,
If not at place of deatli?
flow long at
Place of Oealli ?
Days
ri.ACK oi- niRiAi. OK ki;mo\ai.
dLa>u<w^JJl JaDaJLIu
DATK of HrniAi. (ji ki;Mo\Al.
vUaxj X2» 190 'i
(Address "i^l O 'LjlLuv "$ir.
N. K.
-I. very item of {nforinntion •hould be cnrefully Bupplieii. AGE should bo stated EXACTLY. PHYSICIANS should
HtHte CAUSE OF DEATH In plain terms, that it may be properly claHHifled. The "Special information" for par-
sons dyinft away from home should be itiven In every instance.
I
\
1
1
:\
:i:
}
"tX
m-
ii
.1
I'M
W^
'»; Ki
II
\m
n
V
Iv •
IM
Ji i
\-
:I|I'
t
t !
WRI
TE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
})n;i-.! r 11
. altli I So. \K -S-ST^^ Hit I' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I)(ff(' FiJPtl y
(A^Cr\.^^-^^w^
Xh
I'JO'i
Registered JYo. ,
1 1 m
T~S .•-*-> ^
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ceitificate of 2)eatb
( H. S. Stan^arD )
PLACE OF DEATH: — County ofUOo^^ J^vyOLAv^^o^ccCity oiO/O^^ OAXX/vx/^^A.A.^^i^
No. ^LccVO^ ViD .€L\t<rvu
0-^kd.oJ-. St.; —
T)ist.; bet.
and
/ ir DCATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION • \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
^1 â–
FULL NAME JJCm\AA
si:x
PERSONAL AND STATISTICAL PARTICULARS
>!• I'.IKTll
I Moiitli)
C^
^ \ Vra,
uu.
(Day)
M.. tit In
MEDICAL CERTIFICATE OF DEATH
DATK Ol- I)I:ATH
I go I
(Year)
(V«;,r)
/)<; r.N
SINt.I.K. MARKIKI).
WIDnWKI) HK DIVoKiKI)
tWritr in s(Kial flr-^i^Miiiliou)
HIK THlM.Ari.:
(St;it« or CoiMitrvi
X
Cl\
fatiii:k
Hik riiri.ArK
f'l' I ATHHK
'Sl.ili or roniitrv
MMDKN NAMF
<•) MOTHKR
III M(»THKR
(Sta(«- or Coiintrv
OCC
(Month) K (Day)
I HI;R!:1{V CI:rTIFV, That I attendcMl deooased from
LLuvX^^Jo 190''- to LAjwA-Ol. .OnX 190 H
that I last saw h •• aHve on VA.a»a.^ /^.l 190 S
and that death occurred, on the date stated ahove, at VO
Uw M. The CAISE <>F I)I':ATII was as follows:
) /^/ W.'&.^CLAL'oJtA^i:
rv^OL^_A„'^wv- V tr'ys^w O-
Hours
t^f^ldfd III \iin /'i mil iuii \ ]',tll^ ~- yfi'tltll'
Special Information only for Hospitals, institutions, Transients,
or Recent Residents, and persons dyinq away from fiome.
Ihn
"'l;,^'!?^'''- ^1' '^â– 1*1:1) I'KKSONAI. I'AKTirri.AKS AK1-: IKIl-: TO riiK
»n.si <u- MY KN(»\vi,):i)(-.K AM) ni:iji:i-
(Inr.inirint Ijj ,'
^YY\J
< \.l.lr<-ss S 'X\
(^u
1
Former or
Usual Residence'
Wl»en was disease contracted,
If not at place of deatli?
Hew lonq at
Place of Oeatfi?
Davs
y.ACK OF HIKIAI, OR RKMOVAl.
\JX.K/s>a)^
I NDHRTAKKR
(Address
Vil- v}axx>c^ ^^ \Jj
DA TKof Hi KIAI, or RKMOVAI,
LL0.XV '<X\ 190H
r^
9
DURATION ^''^''^ MoNl/is "X Days
CONTRIIU'TORY J &'%Ol>\'^.'VVa-<X CAa^^
1)1- RATION Years .Souths Davs Hours
n ^ ;^
(Signed) \x J. O/Ol/^^Uv-v , M.D.
ULuX\ O.Xi9o'\ (A.ldrrss) IS I CJaaJUja. 3.1
N. B. Kvery Item oj? information shoultl be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for per-
sons dyin^ away from home should be £iven in svery instance.
4
III
•■?
;l
•
I'
;â–
r'
44
m»^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
)',n:i;
I I . ; ; ! t ll - !•■V" 1 '^ '^'.^^ ^^^ •' *-"^'
Kcr&n lO BmCK Or CERTiriCATE rOn i N3TnUCTiv/i^I
f
iij.
f f :
m
It .'
â– \'
h f-
IpfH^
XZ
locn
Registered J\''().
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=-City and County of San Francisco
Ccvtificate of Bcatb
11. S. Stan^ar^ )
J? ^^ , I ^
PLACE OF DEATH: — County ofQ-Cy^-v J Axvy>vCMiC(City of 0/CL^w J AXXa^x/cla^ <:^
<)
'Cul;
St.;
Dist.;bet. —
and
/ IF DEATH OCCURS AVWAvIfROM USUAL RESIDENCE give facts called for under "special INFORMATION" "\
^ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
JUy\j\^'
PERSONAL AND STATISTICAL PARTICULARS
C<>I,«»R
I KIKTH
M\
>+>
V
M.iiitlO (Davt
OL^
IVCX.CLa^>4
MEDICAL CERTIFICATE OF DEATH
DAI'l-: Ol- Dl-.ATH
a.o..
(Day)
(Year)
AC I-
HS
) I'tU -
M.-mh^
(Year)
n,i\:
"^IN'. l.K. MARK n-; I)
WllH .\\ 1:1) OK DIVi iKt*)-:i)
<N\i:|i in <(»rial <lc>i>.Mialii)ii)
(Stale iir < -MiMit rv'
NAM I- OI.'
lATM IK
Hik tun. \<\-
'»!■J atiii.:k
(State- .11 Ciiuiiti V
MA!In.;x N \M)-
*)I- MOTIII-K
niKTHIM.ACK
Oh MuTlIl-.K
(Stale or Ccmntiv
\^^y\j
(Mouth) i\
I ni:Rl<:i{V CI:RT1I'V, riiat I .-ittcn.UMl (lecvased from
LMvAwO U;o'v to LLL/A.yQ« A.D KpH
f n 0 '. .
lh;it I last saw li '• > alive nn \.A^*wA-Q ^^L- lyo A
and that (U'atli occurred, on the date slated above, at H O vj
V.i M. The CArSI' Ol" 1)1-: ATI I was as follows
A . ^.\
DIRATION )V<7;
(.ONTRIIUTokV
Moulhs W Days //our
.....O.JL^.-ii.^k
I )r RATION
oc
f^'''iJf,> ni Stni I'lamisrn
H
^
//ou)-s
(Signed) lU cOIXxaj d. J JL<yv-|.Aj-. m.d.
ll 100 H (Address) ^ I 3i UA>JI1jUm Bl.
Special Information only l«r Hospitals, institutions, fransients,
or Recent Residents, and persons dvini) awa> from tiome.
Former or
Usual Resident
e\] I U/Y>JU) VJ /OAJ^v v.a^ pidfe of Der
Death ?
Days
)'(•(/ »
M.>titli< - f>,t\
' '",';,^'!V^'^'- STATi: 1) TFRsONAl. P A K T h" ( I. \ K S AKP f k • i-; f, . llli:
'''â– >' Ol- Mv K\.)\\ij.:i)(-, K, AM) in:Mi:F
(Inf.,:
bo.Qm ^
0\.^^^\^\^ <K^<^o „ <
\.l.it-(
When was disease (ontrarted.
If pot at place of death ?
ri.AOH Ol- ni"KiAi< OK kj;mo\au
(^u OiL.^
INDl'lKTAK
nxri'df jtiKiAi. (.1 ki;m()\-ai.
T9o'\
A.i.h-.ss ^ HO^ O^cA^v^cU *" c5l
N. B. — .
F.very item of informtition fthoiihi h;.- ciirofnlly supplied. A(1B should be stnted HXACTLY. PHYSICIA>JS should
Htatc CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for p«r-
S'>n8 dyin^ nway from home should be ftiven in every instance.
k
n
t
,t .
I
. i L
'd
: (
W
â– t M
i .
%
\V\U
\.
ii'
ife^^»^
â– '"'^
m-
l|lf
U
f!
^
i|!
IWI
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
H.MKi oTHr^
HS. l> Cn
â– rrrn Tn RAr.K nr rpRTirirATr POR INSTRUCTIONS
lutlv Filed, (Ja./.<VLA^^ /^^ 10 0\
Registered J^o, 1 1 65
,v^ Deputy Health OfTlcer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Death
( H. S. StanDarC* )
PLACE OF DEATH: — County ofO/<X^w JAx>^^A.^ui.coCity ofCV^X^v 0
No. ^ C) lo dL cL^\ , \k'^>-^
(
St.; H Dist.; bet.^/U.Xl/Vva/VY^Uvv and
ir DEATH OcfcuBS AWAY FROM USUAL R E S I D E NC C G I V C FACTS CALLED FOR UNDER "SPECIAL INFORMAT
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBE
i
-'^•io
N)
FULL NAME
O^'^rrx.'
>AAj-CX.A^?v:\j.
--1
PERSONAL AND STATISTICAL PARTICULARS
I COI.OR
'>! HlKfH
iMc^iitli)
b'^> »„,. \^
W'
(Day)
.1/- -,//// A
\
, I'A-H
(Year)
Da 1
MN' .1,1". M ARklKI)
Wllit >\\l.:i> OK I)I\()krKI)
\^;.â– â– Ml v(.ci;il <k'si>.' nation)
ItlR rilPI.ACK
' si:iti- or (,'<nniti \
N WIl- OF
»-A IIIKK
HIKTlU'l.ACK
Ol 1 ATIIKK
(State or Country)
MAn»K\ NAMF
<•! M'lTHKK
RiRTirrr.ArK
<H' MnTllKR
'St.it.- or C'(inntry)
<1
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH
(Month)
'J
XL.
(Day)
I go \
(Year)
I IIIvRKBV CI{RTIFY, That I atteiuled deceased from
•'.:.-■■■: 190." — ~- to IgO ■■"
that I last saw h - alive on 190 "^ "
and that death occurred, on tlie date stated above, at '.
a: M. The CAl'SH ()!• Dl-ATII was as fallows:
1)1" RAT ION Years
(.ONTRIHUTORV
Mouths
/Jays
Hours
.\.«^OkjL
"'^'"I'ATION
<xj^n.j5^
DTRATION
Years
Mouths
Days
Hours
(SIGNED) ur\.cn^Ji^^ oAij.UJ.X^ M.D.
\Xkxj^ H rr)oH (Address) V-^\^Vu\\<) UXlv.t.X
H i>. I"
:dlAL IN
Special information only for Hospitals, InsmutllJrts, Transients,
or Recent Residents, and persons dying away from home.
M..nflr
/)rM.
,:,M!'*^ *■- ^'"'^ •■»•■." I'HKSONAI. 1' AKTICn.AKS AKI-. TKrK TO TFIH
nhsr OF Mv^^•.)\vI,):^(•,J^^ and ukmi:f
^I'lf'iMuant
r\.i<i
n -^s
-I
Former or
Usual Residence
When was disease contracted,
If not at place of death?
Hew long at
Place of Death? Days
1»I,ACK OI" m'RIAI. OK KHMOVAI,
DATl^of nt RIAL or KKMOVAI,
CrnjG iDi^A>^
(Address i X C) ^ \| |XA.,^<;L^^L^-^<nyv
.X^.
i9o'\
^Ka>-^;u
N. B. F.very item o? infformation should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for psp-
«on« dyin£ away from home should be (iven in svcry instance.
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c*>^'CrL>cA^ c
PERSONAL AND STATISTICAL PARTICULARS
vl JUy-^r\.<yJLx Uj JvaXx
I! I Kill
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Deputy Health Officer
liegLstei'erl J\^().
um
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of H)eatb
( Xl. S. StnnC>arC> )
PLACE OF DEATH: — County of U/Cl/y\; 0 AyCL/Yv.'C.i^c.l City of O/Oyvu 0 ^v^Ciy va„-.\,><lc-0
.. ^OL-yvLA\; St.; '1 Dist.; bet. 0 XUAAJlA^ and jJ (rl^\>U
( "" .°/*;tl°*''''"'^ *'~*'' ''''°'^ ^SUAL RESIDENCE GIVE facts called tor under 'special information- \
V IF DC^tH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
V^iLA-
FULL NAME Vyg/v^o^di L,<u
%
I
HO ,v,„,- a
(I)av)
M.oilh.^
MEDICAL CERTIFICATE OF DEATH
DATH oi' DI'.A'III
(Month)
'Day) (Year)
/ 1 Id H
(Vear)
'AS
/)<M.V
^iN' li". \t.\KRii-:i)
W!!'i i'\ ID , ,iv' in\-, iKTI-: I)
"-ii- Hat i. â– n I
5F{HV CliRTlFV, That I atteiidcl doccascl from
'1 Icp'^ to LLa^^. /XO T(p'-(
wli ^'' alive on LA-Va^O. CV 0 up V
and that dtath ..ccurred, on tho date stated' al)ove, at
31. Tlie CAlSlv OI' DI-iATII was as follows:
1)1 RATION )\ars
CONTRIHUTORV
Months
Day
Hours
Afou(/is
nr RAT ION' )\uu'S
(Signed) J. J\, kjxaXXjlIx.'
/^ays //ours
A^- v^ M.D.
XX TQoH (Address) I C)^'^ U <X.UL/\v<iA.o.- n
lt__
SPECIAL Information only tor Hospitdls, institutions, Transifnts
or Recent Residents, and persons dying imay froTj fiome. •
lu.M (,i. M^ KNOW i,i;i)c.H AM) i!i;i,ii:i-
s AKi-: TKii-: Ti} rin-:
<r>v
former or
Usual Residence
Wfien was disease contracted,
If not at place of death ?
HoH long at
Place of Death ?
Days
A.Mn.s. l^^^O - 15 tlv.. '&i
I'W^CK ()]• MIKIALOK RHMOVAI. l)An.,,,f IUkiai. <„ Hl-MoVAI.
R H ^ \rrtui><Lv<rvx dt
'A.ldi.'ss
•very item of inlformntion should he . jircfully supplied. MIK should he stnted KXACTLY. PHYSICIANS should
Htnte CAIISI: OP DEATH in plnm terms, thnt it miiy he properly classified. The "Special Information" for p«p-
'^ns dyinft nway from home should he <iiven in every instance.
•l<
li
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WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
,;.,.,,.! â– !l '''i 1- No. ;^ c"-:_-5k;--^-. MivrCo
(ffr /'V/^^/, UwV«w/CVuv^<iJtj
PERSONAL AND STATISTICAL PARTICULARS
COI.OK \
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
ItJO'i
Bpgisto-ed JVn.
110?
0 j^
/v-^ Depu r
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
{ "U. S. StanC>arC> )
PLACE OF DEATH: — County ofO/CLo^ J A>CX/Yv^\^C(City of Q/CL/ru 0 J^^XXyy^.Al^^<i.<l.o
urs/Tawav from usual RI
(IF DEATH OCCURS/IaWAV FROM USUAL R E S I D E NC E G I VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" "\
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
Dist.; bet.
CAL
NAI
and
^'1
(Dav)
1/..;////-
(V.ar)
IC
/\!
I go \
(Yt-ar)
that I last saw h X- . . alive on
Xjysj^iXj^
MEDICAL CERTIFICATE OF DEATH
DATi-; »)!• i)i-:ATii r^
^Montli) K (Day)
I in;RI{l>A' Cl-RTIFV, That I altin.kMJ .Icccased from
Ov5 190 H to AXo^.^ l^ TQoH
LA.AX<3 . ' Tip ',
and that death occurred, on the date staled above, at UXO
y ^r. The CAISI-: Ol- DI-ATII was as follows:
1)1 RATION }V<7;-.? JA »;//// v /^<7j'.s-
C" < ) N '1" R IP, r T 0 R V J juJ^AJ\jqj^kXjqC \j UwdUyvvJU^..
.NJ ~
Hours
DIRATION ^ };v7;-.?
(Signed) J
YVO/'^ Cu
.4
'-'''' 'I'-'f III V,,„ /•,,,„, /,H-„ n )■■„-;. >i 1/.. ,'///- iO /'
CL
A^X:^ ^C TOO
.^foiit/is
(Address)
/hrvs
ve.
flour:;
M.D.
CH^Ut.
'•'>i oi- .\n, KN(i\vi.i:i)c,}.: and i!]:i,i};i-
O-CL/rv.v-tcx.O
Special Information only for HHspltdls, institutions, Transients,
or Recent Residents, and persons d\ing anay from home.
Former or ? ) J %^^^^^^^^^^^ ''^fioH long at
Usual Residence v^Ve4\X) 0\D frvvCiX Place of Death ? T.
When was disease contracted.
If not at place of death ?
Days
o rill-;
ri, AC}-: Ol' HIRIAI. OK k}-:mo\ai
i
rNDl-.KTAKl-lK
(A<lrll<"iS
DA'I'lj..;" Hi KiAi. or Kl-'.MnXAl,
-very item ui irilr\)rm»ition 8h«>uld be carefully supplied. M\V. hJiouUI be Htiite.l liXACTLY. PHYSICIANS Hhould
'tHte CAlJSi: or DI-A TH in phiin terms, thjit it miiy be properly clasHificd. The "Special InyormHtion" for p«r-
i'>n8 (l\ ini> nwnv (mm hnmo uN^ai.i.i k.. a:..... \,% ^.,..., ino^nn^o
«ons dyJnft nwny from home should be feiven In every instnnce
MP
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'MY'
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WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
tu-F'sr&fT*; ^*^=*i:r«p "'^ '' *-"
Dale Filed . LLuvxaAyLAi) X\
d^.-<yV-AA^
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
(IF DEAThAoCCURS AWAVlFROM USUAL
IF DtAmM OCCURRED IN A HOSPITAL
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
COI.OK ^ . ,^
<I)av
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
1U0\
Begisfcred J\^o,
1168
Deputy Herlth Officer
Certificate of H)eatb
( Xl. S. Stan^ar^ )
Si % . J?
m
PLACE OF DEATH: — County ofO/CL/YV JyV(XAXC<vXiya<: City of 0iO.yy\j J ^UDL/wCA^^yXM^
Dist.; bet.
and
RESIDENCE GIVE facts called for under "SPrCIAL INFORMATION'
OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER.
)
OlVVi
/lIH
MEDICAL CERTIFICATE OF DEATH
DATK ()!• DKATH
a?)
.i/.-»////..
(Vt-ar)
/',n
( Month ) A (Day) (Year)
I in-iRI-RV CI'RTH^^V, That I atteiKkMl deoeased from
'^5 1 190 I to LLva./Ql Q>.'^ igoH
til at"! last saw h ^'- ' - wilivc on La_a.a^ vvl
rep
aii.l that death occurred, on the date stated above, at ?)• ^ 0
LL M. /rhe CAISI- OI' DICATII was as follows:
<:x^^j\M
CXw>^v\ycL
I) r RATION )Vv7/-.?
CONTRIlilTORV
)'t'ars
Mo)i(hs
/hivs
I /ours
^^o}lths
U ^O^^V' v<
1
DT RATION
(SIGNED) LL\i^KA,v\.' JAf iT 0-
LLo^QX^DoH (Address) "at
/^avs
SPECIAL INFORMATION only for Hospltdls, Insmutions, Transients,
or Recent Residents, and persons dying away froni home.
i/..y////-
'llh \It()VK STATJ-I) I'KKSONAI, I'A KrUTKAKS A K )•: TKfK To Tin-
iil-.M «(i' \1\- KNOWI.I.DCK AM) nia.Il-.K
Former or
Usual Residence
?
HflH long at
Place of Death? Days
When was disease contracted,
If pot at place of death?
A'-vXXA^
â– .A
[
ruAci-: OI" nrRiAi. nk rj;m()\ai.
■1, \(. J'. < >!• Ml
rNi>i:KiAKi;K
^AddKvs
"^'"liof" HfHiAi. 01 kHM()\AI,
^^^^^-^ ^% I90H
■• Rvery item of in?opm,ition should be cnrct'iiMy supplied. AHF. should be stnted HXACTLY. PHYSICIANS nhoulcJ
«tate CAUSE OF DEATH in pinin terniH, thnt it mjiy i»e properly classified. The "Special Information** for pwr-
?on» dyin(l away from home Khoiild be Jii^en in every instance.
Tfemiia
i»«pi#
w
l!
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I
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it^mmrmi^i'mi^-
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WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I, ,,,1,1, 1 Vn :: f-'-i^'se^^.USiVCi,
Dnlr nird , IXo^vvxit; X\ 100\
t\.K.^^ dsjiAj-u Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eath
( X\. S. StauDarD )
PLACE OF DEATH: — County of Cj,CL vw OA,<vwtv^r.<<;ity of 0<Xaaj 0 AxX/>A./CAj<i,o,t.
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
IdJxJ:.
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
llegistci'ed J\'*o.
1169
St
Dist«; bet — and
/ lA DEATH OCCURS AWA^ TROM USUAL R E S I D E N C E G I V t FACTS CALLED FOR UNDER "SPECIAL INFORMATION" "\
V U "" DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
XAJi.tr>Aj
n,n
MEDICAL CERTIFICATE OF DEATH
DATK oi' I)i:.\Tll r\
(Month) A (Day)
I m<:kl-:nV CJ-RTII-V, That I attendcMl (leroased from
(Yen)
vAaa/o ^^ 190H
^'X 190 H
that I last saw li *- » > ^ alive on KJ^-XXj^ 'X'^^ i(p 'H
and that death occurred, on the date statecrabove, at *"
M. The LWrSlv OI- Dl-ATII was as follows:
\
-CXi
T)r RATION
) 't'ars
Montha
"u A<Cr\>s^tJk.
Pays
Hours
DI'RATION
(SIGNED )
^.^CA.A.^orV'X
fUb-'
V/tx^..<r\.^'Vw\4
Pavs
.\.^C^VvX
VAy>^'X<XA-VO0u
^ f^'iiied ill Sail /"; ,n/, /.',•,> ^ )V,7/> D M.»ifh< \
/)<7I.
""pvJ'p'Y '5^''"^ 'â– 'â– â– '* ''HKSONAI, 1"\K rirri.\KS AKi; i-Kl 1-: TO
. 0. cxXoHoit/Cr^^
Xh\i)C>\ (Address) 1^)1(0 0/CL-V\;
U /CL.'V\; ML14A.
//ours
M.D.
SPECWL Information onl> for Hospltdls, institutions, Transients,
or Recent Residents, and persons dy'-tg awdv from fiome.
Former or u 1 1 ) -f M ""** '»"•> ^f r,
Usual Residence i ^ ^ U.O^AXw\. KkA^L Place of Death ? A
place
IAaaaLv/v\
Days
1
vnv.
ri.Acy-: oi' iukiai. ok kj:mo\ai<
'OjuL/vvv
DA^Jlot HiKiAr. or KKMOVAJ,
^H 190H
rXDl'.K'rAKI'.K
(Address
-r.very Item otf information shoul*! b^- caret'iilly supplied. AdB should be stated BXACTLY. PHYSICIANS nhould
state CAUSE OF DEATH in plain terms, tbat it may be properly classilficd. The "Special Information" for per-
sons dying away from home should be feiven in every Instance.
m^
.i
i\
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In*'
â– I
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-\ ^jlU'.
â– ^S^^^^^
â– â– HM
Si
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RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
,.,,,,,1 , f ll,.,ltl> I- No. i> -rt-fi^-^iiH&PCo
REFER TO BACK OK ctHFiKiCArt run ir^a i nuo i iu«^»
I)(f/r Filed ,
(y\^>^y\.y^-\y^
an
ioo\
Reglsferrd JS^o,
1170
Deputy Health Officer
DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( Vi. S. StanJ>ar^ »
(^
PLACE OF DEATH: — County of ^<X/Vu 0 AxXAAAMi,£(City of C)<X/~.^ 0^<X/>xa^c<^^o
(ir DEATH OCCURS »W*V FROM USUAL R E S I D E N C E Gl VE FACTS CALLED FOR UNDER "SPECIAL I N FOR M ATION" "\
IF DEATH OCCURRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
Cr
PERSONAL AND STATISTICAL PARTICULARS
!>A1 I', (II- lilKTIl
(Mouth)
\ ' . }•;
o
) '(â– (/ 1
( D.^v)
M.»i//i^
rlSH
(Year)
A; 1 .
^^IN<.I,K. MARKIKI).
WIDOUKI) OK I)]VnKvi:i)
'Writf ill s<Ki;il (U•>^i^.•Il;ltil)^)
lUK riii'i, \('i.:
' St.'itt (ir Ci)iiiitr\i
-^^^^vj^<L
namj: oi-
iatmi;r
iiik riiiM.AOF.
<>|- |-ATIIHk
Sliilc (It (.'oinitrvi
MMI>i:\ NAMl
'" MnTin-:K
niKriiiT^ArK
Of' MoTHHK
(Slatf or Couutrv)
.U<5VMX^^X/W<u
\J
MEDICAL CERTIFICATE OF DEATH
DATH OF DIvATH /^
U-VaX^ 0x1)., /9o'\
(Month) /| (Day) (Yt-ar)
I HIvKlUiV ClvRTII'V, That I attendtMl (Icicascd from
LLuux '^'^^ 190 H to ^olLl
that I last saw h - '^ alive on vAa.\X5 ^^ I90 i
and that death occurred, on the date stated above, at b oO
J M. The CArSl^M)F DIvATH was as follows:
KpH
Dr RATION
CONTRIIU"
) lar.
Moutin 1' Days ^^ //ours
\.XX>v/cL\,/(Xa: d,.<OL<wLs-v>sJC
Xxx)
r\
Ou
CuVcOj
diration
( Signed )
Vi'iirs
M<^nt/is
Pays
oc
X^oJLu
^caov)
La^a^'
,\.XXA<-.iA.'
//ours
M.D.
:)oM (Ad<lress
SPECIAL Information only for Hospitals, Institution^ Irdnsients,
Q.'^IQOM (Ad<lress) (o 1'^ U <:5U
[(iiiAL In
or Recent Residents, and persons dying away from liomc.
^ .\!.>>itl,^
/><! 1.
1U-,SI '>' -^JY KN<)\Vl,i;i)C. H AM) Hi:i,Ii:i-
Former or
Usual Residence
Wlien was disease contracted,
If not at place of deatli ?
Now long at
Place of Deatli?
Days
ri.ACI-, Of- lURIAI. OK Kl'MOVAI,
^
CXy>^
OA'I'Kof IJiKiAl, or K1':Mo\AI,
t ;
T90'\
Kvery Item of inform»ition should be cnrct'ully supplieil. WA. shoiiltl be stntecl F.XACTLY. PHYSICIANS hHouIcI
state C.AUSt: OP DTA TH in phiin terms, thnt it miiy be properly claHHik'ieil. The "SpecinI Information'' for p«r-
«ons dyinjl n\*ay from home Nhould be fciven in every instance.
!;
il
\ i
I
•"Vttfi
mm^-
', t
im
ft' '. iki.'
1
WRITE PLAINLY WITH UNFADING INK
THIS IS A PERMANENT RECORD
, . ; ! 1 . . i i I h
V '
'."*?• 5!*.'A'«^«! Hoi
r Co
H tr en I *«» t3MV-r\ \JT N.. u n I 1 r i v^« i t_ i
^f II I t « ^ f i:^^^^! i^^i
/><'^/r Filed , \j\XA,X)u\juAi IH
/,9/^;H
FiCilLslci'C.d' 'Xo,
117i
I
t_.
Deputy Health Officer
I DEPARTMENT OFTUBLIC HEALTH==City and County of San Francisco
Certificate of Beatb
%
PLACE OF DEATH: — County ofC'CL^^ 0 AXXaoX^a^^lCa: City of CJ/CX/yv >J/UXA/x^v<iX^o
'J
No. b
St.; 3^ Dist.; bet.
(IF Dl
IF
SPI
and
EATH OCCURS Av/ftY FROM USUAL R E S 1 D E N C E G I V E FACTS CALLED FOR UNDER SPBtlAL INFORMATION
DEATH OCCURpip IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER.
\
vl..
X\
)
FULL NAME
• i:\
PERSONAL AND STATISTICAL PARTICULARS
C01,( »K
Mrvo-w.'
Kill
\^ .V:
<1\T
cxJU. 'i I
N!..mli
)V,/,
I);i\i
\ • ,11
I M \ I-; I- 1 1 I )
I;' !• I'lllM. \ ,• !'
•'i^iic or '.'' mill I \-^
!• \Tm;K
lUKTllPI. \. !•:
'"â– 1 \rin-.K
->t.it< or (.'((luilrv^
".' Mi>Tili;K
''•nrnii'i,.\cK
I'oiinti \ ?
MEDICAL CERTIFICATE OF DEATH
DATl-: (II" 1)I;A'III r\
iM'Mltll* K il):iv> iVriirl
I II i;k!';i'\' ci:rtii* V, rii.tt i aucniid d^c asr.i (t,,m
~" 1 1/) to ~ i()n
lli;it I last saw li " alive on i(;o â– " '
and that <lfalli occurred, on the dale slated ali<i\-e, at
M. The CAISI-: OI" I)I:a ril.was as foil. .us
T)''R.\'ri(1N Yrars
CoNTRUU'iOUV
Mouth>
Haxs
I lout
( Signed ) uAxrwtx 0.^0 iJO dOuLoL/\v<JL
-COll i.,o'\ (' \ddnss) Wv^Ovil^ UlL.^
SPECiJAL iNFORrVIATION on!\ for Hospitals, InstitiitiVnV, Transients,
or Reicnt ResidiMils, dnd ppisons dvimj ,ri*.iy Iron home.
[L.
//(>//rs
r/i.D.
IV
.^r•>l'/,â–
III! AliOVK ST ATI-: !) I' l-" R >^( >N A 1. I'ARinTl, \RS ARI' T R I !. l'- < Till
I'.i;ST <)1- MY K.NDW l,l.;iK'.K AM) !!I".I,I1:f
IiirMunant
x<rX.<rvuuvA
. ©||.^
(AiMri's^
Former or
L'suril ReMdencp
Wfirn wds diserfse (ontr.iitrd,
If not a! pldi e of di'.ith .' .
How lonq a\
Pl.j( e of Dfdth ?
Dd\s
PI„\cp: I II |;[ r : > I
CL^wV- A-V. A wU U .CxOs.
s I
nvri';..!' nriMAi. .,i ri:m()\ai.
I \\<: )-, I \ 1. i
TQOH
!\. B. livery item of In^irmntion shoiihl h.- cnrofiilly supplied. MJC Hhoiild ho stjiteil EXACTLY. PHYSICIANS should
stntc CAUSE OP DLA JH in plsiin terms, that it mjiy Ik- properly cIjihsU' icd. The "Spccinl Informnlion" for p«r-
Kons tlyinft nway from homo should he Jiixen in every instnnce.
I 1'^
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I
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i i
■!#*•'
'^â– '^\1
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■m^ WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
ll<:ilth VSn. !> -*'i:^i;ii^ i''^ '' ^ "
Dftfi' tiled J
C\.<J-V^->^^-^
an
7.9^4
JfcQ'i.s/crcd Xo.
il7S
Deputy Health Oflficer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( *a. S. Stan^arD )
PLACE OF DEATH: — County of C' /CX^nj 0 AX>^/v^A>ui/CfCity of O/CL/Tu 0 AXX/vs^C^oft.^c^
No. I C) 0,5. UXoJj-Ol/y>vOu (.-'VjUOA.) St.; 5" Dist.;bct. 11 rWcL and IS Axi
f IF Dr*TH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
<i:x
:'\ 1 1-; Ml lUK Til
PERSONAL AND STATISTICAL PARTICULARS
I COI.OR
XJ^S\jOJj
^
'XjJ\yy\j^
M<.nll\
(I):iv)
At.K
) I'll I
M.»i///<
I V.-ai )
/'(M.
-i\< l,l". MAKUIKU.
W IlKtWKI) OK DIVORCKl)
Wiitriii <i)ci;il <U>^i j.'iKitioii )
0>L/v\.XVVJL
inKTm'i.AOH
-â– t;iir or t'Diintrvi
\ \M1-' oi-
1 ATin-.R
iilk llll'LACK
<>!• FAIUKK
'St.iic or Comitrv)
MAlDlvN NAMK
t)F MO I'll KR
1{IKTHPI,ACK
oi' MOTHKK
fSiatf or Conutrv
J? (^ ft
U (SI
XAJx^^n^
6
m
m
/<Xyy\j Kj Ax>^^y\j:ia^<lai^
OTU
'O^jyxj 0 A>cu''w/^.^wAx:^
OCCUPATION
MEDICAL CERTIFICATE OF DEATH
DATK Ol' DKATH O
(Month) (T (Day) (Year)
1 m<:Rl';i}V CI':RT[FV, riiat I attended .leccasc.l from
LLu^O %\ up'\ to .. LLaAXU 1.^. ic)o\
tliat I last saw h <^ â– > alive on LAvAa^<X. ^^ 190 'i
aiul that death occurred, on the (hite stated above, at vc 5^^ 0
\} M. The CAlSlv Ol- Dl-ATII was as follows:
Dr RATI ON )\'(irs Mo>ii/is Days I/ours
CONTRIIU'TORV \Xo.xAX ^ 'CX..AA>uo
nrRATiox
)'t'a)S
( Signed ). (I VDAA./yk Axx.>cyo^>
W rqoH (Address) Ib'^^ d\00-UMX>v<Lc3±
Mouths Pays Hours
M.D.
Special information only for Hospitals, Instilutions, Transients,
or Recent Residents, and persons d>lny anay from home.
AV
^idrd ill Sdv /'i iiin i>ii> O )'riji\ "^ .^/mif/zs I O / Ki
I'lII-". A!U)VK STATl'l) 1M<:K<.<>N \1, TA K T If r I. \ K S A K 1 : rRll". I' t 111 I-]
ii};sT oi- Mv KNOW!,): DC, J.; AM) hi:mi".f
'Itiforniaiit
-A-AJV-vA^
Former or
Usual Residence
Wfien v^ds disease contracted,
If not at place of death ?
HoH long at
Plare of Death ?
Days
i;|^ACl-: til' lUKIAI, OR Kl-:MnVAF. I DAI'l-iof IUkiai. or Rl^MOVAI,
IN I
> 1 •: R T A K v. R O O^-vxX-.^aJL/ v; -^ -\.<i-<V
N. B.-
-F.very item nt inform.ition shoultl »>l' cjirer'iilly Huppliecl. AGE should he statetl EXACTLY. PHYSICIANS fihould
«tate CAUSE OF DEATH in plain terms, that it may he properly claBsified. The "Special in?ormation" ?or per-
sons dyin|^ away from home should he i^iven in every instance.
• • ' .' <<â–
i i !
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1
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; « : .
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*
WRITE PLAINLY WITH UNFADING INK
!?,-•.! .iT
.. *.**-r"5:.-. us, I.
<v>
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Duh' nii^d, lA^AXiAA^ an I'^o'i
Deputy Health Officer
Registered J\'*o,
1173
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of 2)catb
( "a. S. StauDavO )
J? ^ -^
%
PLACE OF DEATH: — County of
C)<X/Vu 0 A/XAVC^oCLC^ City of O/CL/ru 0 KA^^yy^j^iA^^^L
No.
cLou\)^vcu
HTl JjJUL) St.; ^ Dist.;bct/-^ OUX/\)-v<Jj and
/ IF DEATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION â– \
V If DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
^Y\^.' )
FULL NAME
\yr\)
PERSONAL AND STATISTICAL PARTICULARS
-1 \
COI.OR
0
H I'.lKl'll
a^aXa
\' â– )â– .
\xxyy\j
(Day) (Vt-ar)
Ti
).,i
1
M.nilli^
w
r>,t 1 .V
^iNt.i.K M \KKn-:i)
WIIx iW I-I) UK 1)I\( >R(i:i)
• •\i\\ (k»iij.'n;it ion)
I
>uJL
^Cruj-
0 -Ov/WV/CXyW<.
HIKrHPI.AOH
^i:!'« or Coniitry
NAM}'. OJ-
FATin:K
ItlRTMlM.ArK
')I" KATHKR
'State or Conntrv
Nt \n>i:N namj:
<•! MOTIIKK
I'-Ikrui'LACK
'•! MOT! IKK
Statf ..r Cotiiitrv
orrfi'ATioN
AVv/(/r--/ /,/ S,;>' / 1,111.1 1,1 I 0 )V(M >
(J XKyVwXXo vu
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATH
^Month) A 'Day) (Year)
•Rl'iHV CI:RTIFY, That I aUciuUtl (Icccased from
'bo loo \ to LLsA/a XH
I90
\X»wA.A_
i(p H
that f last sa\v h -^?^ alive on VJ^AwA^O. 'X*?.' Kp i.
and that death occurred, on the date stated above, at
•' M. The CArSl- ()!• DI-.ATII was as follows:
DIKATION Years O Mouths I Days Hours
C'ONTRNU TORY
DIRATION
)'cars
(SIGNED ) vjrux/Y d
Mouths
Pays
I lours
M.D.
M„>ilh^
n,!\
I'm, AliOVl-: STATi: I) PKKSoNAI, I'AK lUri.AKS AKi; IKri-: To I" III-:
in:ST OI- >4N' K\(>UI,1|.I)C. K AM) \\yA,\V.V
A<ldn-.s \\ \ J
)t
'\ I
\ i<,oH i
Addriss) ^IH U-<^^JliA>v "ot
SPEOIAL Information «nly for Hospitals, institutions. Transients,
or Recent Residents, jnd persons dying .may troni home.
Former or
Usual Residence
Wlien was disease contracted.
If not at place of deatfi ?
How lonq at
Place of Death ?
Days
11- lURIAI. OR RI-:M(i\AI, j OAl'lLo! IJiKiAl, or KlCMoVAI,
jISUn^-^H ' ^^^^ ^<" '90S
^•Vdilrc'ss
N. K.-
-Bvery item of Information should be cnrcfully Hupplioil. AGB should he stated RXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plnin terms, that it may be properly classified. The "Special Information'' for per-
sons dyin^ away from home should be feiven in every instance.
^#1^ \
•^
i 1 %l
^•>!
• i
Ml
\^'- t'
) -
\:\'
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«
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=t
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'•»'K^
1
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WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
! ! or HeHttTT— T ?<w. t> -^
Ihth' Filod ,
V:i 100\
Deputy Health Officer
Be^istcved M'o.
1174
No.
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( "U. S. 5tanC»arO )
J? op -^ ^
PLACE OF DEATH: — County ofO/O/-.^ 0 ,rvciywt<ACcCity of^'-CX/w. OAXXy%-viLvA.C'0
^â– \o5 LILo^ St.; "l Dist.;bet. cLaX^*^\.O.i and ^A^UX^vO/^
/ IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR Ur*i)ER "SPECIAL INFORMATION- ^
( Tf DEATH OCCURRED .N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTE*<JoF STREET AND NUMBER. )
FULL NAME
'VCXA-^Aj
Kjy\Sj
PERSONAL AND STATISTICAL PARTICULARS
111.
COI
Ol/V
DAT I". (II ItlRTIi
\<.K
KxAj
'"' loivju
M.iiini
^
) ra>
H
b
(Uav)
M. mills
'Vt-ar)
Da r.v
-^IM.l.l'".. M\kKn:i)
WinnWl- 1> (tU I)IVnKvi:i)
Wiitciii "-iK'ial (l«sij.Miati<in )
lilKrill'I.M'K
StMtc <ir C'nuitrv)
lATIl Ilk
HIRTHri.ACK
')|- 1 XTIIl'lR
MAIDJ-.N NAMl,
<»I MOTIIKK
-vu^^
t
MEDICAL CERTIFICATE OF DEATH
DATK f)F DKATH
• Day)
IQO '1
(Year)
fMontli)
i lIl'RlCr.V Cl'RTII'A', That I attciKkMl deceased from
' 'V up H
Ha-^JLu '*^ iQo'A to
'' Q • • n
thAt I last saw h-t/>n alive on ^^^v-v-O
and that death occurred, on the date stated above, at
Ll :Nr. The CAT SI*; Ol- I)i:.\TlI was as follows
CI
Wxrw^^w'CL
%
J.JiU'^.AX^tiJi-
Crv dtjuxhjb
Dr RAT ION Years Months ^ Days
CONTRIIU'TORV ^ciJL^::vA^<X/ .c4 .A^â– V.^,^:!^
P 4- â– ^
Hours
DIRATION
)'iars
Months
Pays
lUKrui'I.ACK
OF MOTUIvk
(Stale or Comitrv)
OCCTPATloxAo- f) \
AVa',/^,' /;/ S',;;/ /'i (1 Ih ism
) 'riU s
Mn„lll
n,i\
i'lll'. \Ho\I*. ST \1")',I) I'KK'-nNAl, I'ARl " T 1. A R S A K l. 1" R r l'. l* » 111)-:
lUvST ()!• MV KN<>\VI,i:i)C,H AM) lU-.MI-.l-
'lllfiiMlKltit
V^-N \_X
(Signed) i]\^X/y^j^ ^-^^Jo^y^yy-^-^Y^
IHiQoH (Address) S lO VJoiil dt
Hours
M.D.
Special information only for Hospitals, Institutions, Transients,
or Rfcent Residents, and persons dying away from liomr.
Former or
Usual Residence
Wlien was disease fonfrarted,
If not at place of death ?
How lonq at
Place of Death ?
Days
i)\ri;o! lu KiAi. oi ki-;m(>\\i.
I'LACi-: »>»• lUKiAi, (Ik ri:mi»\ai,
ten cr\ f
^Xddifss
1
N. K.
-livery item otf inVormation shniild h.- csirct'ully Hiipplieil. A'lfi shoiihl he stiite«l FiXACTLY. PHYSICIANS lihould
HtHtc CAlISn OF DEATH in plnin terms, that it miiy l>e properly clussiTied. The "Special Information" for p«r-
Rons (iyin^ away from home shoiilti he ijiiven in every instance.
i_t:»
' » 1
r
la 11
\ •
â– tl
»4'
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I
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#*^r*^'
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*
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
•n*'
f TT^ntrh^i^^o I V ^^^22'.^^ "*^ •' *• '^
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
1 '^
Rrgisfci'cd A>>.
1J75
/VKo Deputy Health Officer
DEPARTMENT OF ^BLIC HEALTH=City and County of San Francisco
AVA>V^
Ccvtiticate of H)cath
SI (^ Si
(^
PLACE OF DEATH: — County ofOcu'^'\j O.^CX^^VO^CcCity of O/OlaO; O^V<X/%A.'e.c<L'C-<:)
No. Illio 3^(rv^'vlv'a.\,cL St.; 1 Dist.;bet. cL<XX.k,c^^ and V) CnJ\
(ir DCATM OCCURS *W*V FROM USUAL RESIDENCE give facts called for under "special INFORMATION" \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
a, L^iJl,
FULL NAME
.ly^L
v^
sj:\
i> \ ri-; oj inK III
\ - . I-:
PERSONAL AND. STATISTICAL PARTICULARS
<x.L
0
'Day)
/ L
SO.
•-INt.I.}". MAKkli: I).
U IlXtW Kl) OK I)l\< »K» I I)
Wiitt ill v.HJal ilioivnatiMii)
' State or (.â– oiiiitrj)
NAMl-. ni
» ATin;R
inKTlll'I.AvK
<)!• lATMKR
'Stat.' or Coiintrvl
MAIDKN" NAMK
»M- MOTHKK
lURTHPr.ACK
<>!• MoTHHK
'Statf or Countrv)
I Year*
/>,n
MEDICAL CERTIFICATE OF DEATH
DATK ()!• DKATH :'~\
11
(Month) jf (Day)
L m-RIvHV Cl-RTII'V, Tliat I attcii.kMl dccoasctl fnui
(Year)
LLc^C^ iS i^H to Uv-CCQ 11
(T
.'Mid that <lcatli <>cciirrc<l, on the date stated above, at
that I last saw h ^• alive on
a.
M. The CAlSIv ()!• DI-ATII was as (ollnNvs:
vA^Lgla v<L
1)1 RATION y'ciirs Moniln Days I /ours
•^ "^ IJ'A IIDN /7)
X.
<x>x^>cL
h'fsiiiftt ill Stin /'i tiihi.^fo lO )',,ii<
diratiox
(Signed )
a
}'cars „ lo Months
\
Havs
L
0-K.^ti\.'
â– X
K^KJX X'h iQoH ''(Address)HSb Vl ll^n^o^A^. It
I Ion IS
M.D.
SPECIAL INFORMATION only for Hospitals, InslitufioUs, Transients,
or Recent Residents, and persons dying away from home.
M.niili^
Former or
L'sual Residence
Wtien was disease contracted,
If not at place of deatli ?
H«w long at
Place of Oeatli ?
Days
TIIK AHOVH STA'n:i) I'KksoxAl. I' \ k f U t I. \ K » \ K 1- IKl l- T< » llil-
in-,si (»i MY KN.iw i,!;i).;k wd iu-:i.ii:k
niif.iMuatit
V-^^IjlaX^
''\'Mn-;s I'X'X^
it
n.\(,i;ni lUkiAi, Ok rkm<»\ \i.
\A^ c
DX^J-o! ItMMAl. oi Ki;.M»i\AI,
'^5 I QO " \
(Ad.ltfss IS 1H OJwO-^^td^v OI
N. B.-
-Kvery item of inforniHtion fihoulii b- ciircitully supplied. AfiF. sMould be stated fiX \CTLY. PHYSICIANS should
state CAUSE OF DEATH in phiin terms, tluit it miiy he properly classified. The "Special InformHtion" for pwr-
8on« dyin£ away from homo should be ^ivcn in every instance.
I
â– â– !'
1 T4-I
,ih
ji^
: \
ICJ.
>-^*^
'^>M»fl.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
»**jr^j
'/. ..o
i; (TTt nfTfcHitii- r' No ^ ^ ~ '^,,Z-',i~*' "^"^
HK,ht.n lu »Mv;r\ ui- vjtH iimca r& kum insihuctions
It
t
lutlc Filed, (Xu.a/L^t XH ^^6>H lie gi sieved J\'o, 1176
Xo-c^.^^ Xii^vo Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco
Certificate of 5)eatb
1 11. 5. StanDarD j
PLACE OF DEATH: — County of 0/Ct^ro J^UXAVtAjH^c^-City ofO'CU'-ru Z J-^^<xyy\^:i,Kj^'r^Ai
No. 1 IS
(
St.; S Dist.; bet.
IF orykTM OCCURS AWAY FROM USUAL R E S I D E N C E G I V t FACTS CALLED FOR UNO
irlptATH OCCURRCD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD
and Ua^Lola;'VO,<
'special INFORMATION" N
ITREET AND NUMBER. /
FULL NAME
sd^jo
\i
PERSONAL AND STATISTICAL PARTICULARS
!'
A«,K
I HI Kill
Month
1^
)
II
'T
(Dav)
M.nith'
I /
Vi'iir)
/'„'â–
'^IX'.I.I" MAkUn-.I)
w n>o\\i.:i) OK iM\< »Ki}:i)
'Viitc ill MM-i;il <lfvij.'ii;iti(iii)
iMirnii'i, \i-)-
' St:iti or t.'iiiinti \
1
WMl' (>I
I* AT HICK
IWk I lll'l. A,).-
<>l" lAllll.R
Statf or (."ouiili \
"•I MOTMI-'.K
inkruiT.ACK
<>i' M<)Tm<:K
(St:il< or roiinlrv^
I r AT ION-
MEDICAL CERTIFICATE OF DEATH
DATK (»l- I)I;aT11 /O
(Month) /\ (Day) (Year)
I HI'RI-HV CllkTIFV, Tliat I attended decoased from
LLu^. X'h 190 i to \Aa-v^ X!i. i<pH
tliat I las't saw h-O^^x alive on vJwAa.-Oi A?> y,p \
and that death ocenrred, on the date stated above, at VD • O 0
Vj M. The C.\rSl<M)l- DliATII Nvas as follows:
Dlk.ATION Years
CONTRIIU'TORV
Months Pays
DrK.ATIO.X Years Mouths Pays
(Signed ).m/A'vxju 0. Vjaju^Julm
Hours
flours
V\ iqoH (A.ldress) ^Ob O.A^U:ijLAj ot
M.D.
VJ (y\jfcjL>u
/^iilrif III Sail /'i nil, iK,(> Ao )'i(}i
}h>ii/hs
Den
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
Former or
Usual Residence
When was disease contracted,
If not at place of death?
How lonq at
Place of Death ?
Days
nil- \1{()VK STATKI) PKRSONAI, I'AKTICrUAKS AKI-: TKIH TO Til)-;
'n-.M oi.- Mv KNo\vi,i:i)c.H AM) mi:mi-:i'
I'lf'iniiaiit
lis M /o^y. Ot
^X.Mr^Ks
I'l.ALi-, OI- in
OvCyAi,/QL.
JM^\CK <M- lUKIAI, OK KI-:MoVAI. I DAD'ol Miki.ai. or HI;Mo\AI,
\l rLa.x>.v<}.y^ Uc.
(.Ad.
• •*• Kvery item of Information should be cnreV'ully «upplieci. AGhi should he stated RXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may he properly classified. The "Special Information" for per-
sons dyin& away from home should be ftiven in every instance.
it
r';3
U..
:
li
j-i
■»â–
I •
! t
t,
• â–
II
! 'â– i
il
1
.;
J ' I !i\
!
1( ••
''W<
%
I
>'>«H^
li
^U
h*', ,i.
R,'..
Kj'^'if" '
j-^
:-â– ; ;^(
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
'I II t-«t II''
'<,»- ,-, J*fcffr%n.5L:
II V- I> I •
iprc-D -r/^ BAr>u <-»e r^eoTtcm atf eno i m qtoi i^ti/^m<
/iii/i- Filed ,
X\
190\
liegisfcred JVo.
1177
^x^j^^K^ ckji/v-i^ Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificatc of Bcatb
( *U. S. StanOarO )
4
%
PLACE OF DEATH: — County of 0/CXyvu J^uxoo/CUi^C^ City o{0,0<yy\) 0 A.CUtxx:\.xl^c
No.
150^
(^
fs
.^XA^VvvAW St/, "). Dht.; bet. U /CLCVOLA^^ilA'vU and
(IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL I N FO R M ATIO N " N
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
Aju
XXy^rx.'TlyO
PERSONAL AND STATISTICAL PARTICULARS
i:\ ()r\ ^ \ coi.oK
1' • ' 1 ' >1' 111 Kill
oJuL
K^tx
Muiitli)
\' .1-:
X\
)>,/<-
5
M.>tilh
(V.-.'ir)
/^MA
â– -IM.I.i:. MARK li:i)
\vii)(t\yi:i) OK DivoRiKn
lUK ruiM.Ai"}-:
' St;if(.- or Coinitrvi
N \M1- ol
I Ain j;k
HIK llll'LAiK
'»' I \iin:R
--t It' Ml rMMiiti\'
MAIl>l-.\- NAM1-,
"1 MoTHHk
llIK'lHIM.ArF
<»» MoTin;k
'Stalf or Coiuitrv*
\ (lit)
190 \
(Year)
MEDICAL CERTIFICATE OF DEATH
DATi-: Ol- i)i;ath r\
^Month) A* <I):iv)
I lU'iRl'J'.V C1;RT1!<V. That I attondc.l (leot'ascd from
I Ic/d'\ to O^AA/V XH. i()oH
that I hist sViw h -'-^o aHvc on vAA-^V-^ 3. H up .
atid that death occurred, on the ihite stated above, at \'X^
LX ^I. The CArSl-: OI- I)I:AT11 was as follows:
0 AAXM-N./e^jJLeH3.Au> U AAX/YVV/CrvV-Ow^A, ,
K.<X^
I >r RATION \ Years
CONTRIIU'TORV SrW.
,:vaX
Da \s
Hours
DTRATK^N
cars
Months
Pays
oJlLuL
^i^^^/W'C.Ou-,--
O^^^^-^CtA-AAaj
• '^HTPA'I'ION
fyrsidrd in Sim i'l tin, i^fit ^^ \ )V,;;>
(SIGNED )
LLl^'Q iHiqoH (Address)
:ilAL Information only for Hospltdls, institutions, Transle
SPEC
or Recent Residents, and persons dying away from home
lelits,
\r,uiU-
/',,i <
Tin: AHoVl*. STAri-D I'KRsoNAI. r\R llil I \Rx AR )• !' R T }•; li » 111 1!
iiKST Ol M\;^ KNo\vi,);i)c. !•; and iii;i,ii r
1 nt'oi maiit
juy-oo-JL C!d. jj.
Former or
Usual Residence
When was disease contracted.
If not at place of death ?
Haw long at
Place of Death ?
Days
I'l.ACH Ol' IMRIAI, OR RKMo\\l.
^^J^y^>vaXwu
DA^llof IHkiai, or KKNH)VA1,
I M)l
•; R T A K 1 -: R vJ oaXjl^j \^ LU Jl-V". J- _
'Address HX'i jcrLdlx/vAj "^ /cvAx ULa/A,.
>. B.
-Hvery item of informntion fthouUI be cnrefully supplied. \i\V. should be stated EXACTLY. PHYSICIANS should
state CAUSF OF DEATH in plain terms, that it may be pr»)peply classified. The "Special Information" for per-
sons dyin( away from home should be given in ^\^ry- instance.
II
I
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if'
â– I
iT
1 1 \
• :
II
\
wiikH.-^
WW
W^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
. mfr-^rO:^ 1)6- l<
.■*l«^i^i^> »•
IKl^^^ti ^'mm â– ^^ Ai i
>urt.ri iv^ b><>%\i>r>%^r v.<wriiiriv«>iiw r%rfii |i«^rirtv\^llV/i^<9
â– (
4
I
.
/yc//(' F/7,"ff,
i â–
a^
^^t^'i
Bcglstcj'ed J\^o,
1178
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( "U. 5. Stan^ar^ )
PLACE OF DEATH: — County ofOOU^r^ JAXJ^/rvc^^c^ity ofCJo^'>x' i KAX/-Yy^fL^.J^^^<>
'â– ^^.
ChJ|W..O^I
St.;
Dist.; bct.~
and
(ir 6CATH OCCURS AWAV^ rROM USUAL RESIDENCE give facts called for under "special INFORMATION" '\
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
-1 \
' \ I i: nl III Kill
COI
UJaxaXji
Motilht
Ai.K
Id?,
)><,■»
(I)av)
!/..>////>
(Vear)
/',,â–
^IN«.I,K. MAKUIKI)
WIDOWKI) «»K 1)IV(>K( Kl)
\\iitt in social ilc-i^'iiatioii)
lUU rui'l. \rj-:
M:it( (»T iiiiuitiy
MEDICAL CERTIFICATE OF DEATH
DATK <)l' Dl'.Aru /'^
(Month) /T (Day) (Year)
I Hl'iUIUJV C1;RTII'V, That r .ittciidcd ilcccasod from
a
190'i to vJv^^/^>Q_ Xlb 190 H.
NAMI- 01
I'A rill-K
MIKTHI'f, ATK
'>! » AIHllR
' St.itc or I'nimti \
MMDl-.N NAMI-
<»I .MnTlIliK
niRTMl'[,ArK
<»H MOTHKK
(Statf or Count rv
'^
n
xCayiV<X.L'V». a-r.
y\A^
that I hist saw h - > > alive on vAA...^^xx 'X'i^ icyo H
and that death occurred, (mi the (hite stale<l above, at b ^:> C
LL M. The CArSlv OI- I)I{ATir was as follows:
Hours
nr RATION l. Yiuirs Months /hivs
CONTRIIU'TORV \f rVxX^LXX.^-
1
OCCri'AlioN (A)
DT RATION )\ars Mont /is Pars
I N E D ) . w rvvu . ^ /OwV^^'v^^a^Dvj^i^^
1?^ T90H (Add ress ) O te . \W>CuJp^ lo (HL^xt
(SIGI
Hours
M.D.
^--Crtrl
h'r-niftl ni Siiii /'i 1! Ill iMi) '' )'f'ais
Months
/ 111 1
I HI-: AIIOVK ST ATI", I) 1'KKSONAI, I'A KT hM " !. A K s ARi; Tkl)-; To IIU-:
lU.sroi. MV KN< (WIJ 1)(,H AND Hi;!,!!",!
Informant
SPEC^AL INFORMATION only for Hos)
or Recent Residents, and persons dying aw-»y from fiome
itals, Institutions, Transients,
Former or
Usual Residence
5^H' \tJ\j 3ir Place of Deatfi? "I ...Days
Wlien was disease contracted,
If not at place of death?
JLa-A.^q-v>v
\'Mr<ss i 3) ^ s3 cr^Aw^I>UkJ ~$^'k.
I'l.ACK Ol" HTKIAI, OK KKMoVAI, I DATI-.o! Mikiai. or KHMoVAI,
'Address I'X'^H VmXX^^J^Uljt ' '^ ^
rNDl-.R'rAKKK
^' ^' r^.very item of informntion Rhniild I).- ciirev'ully supplietl. XCV. Hhould be stnted F.XACTLY. PHYSICIANS should
state CAUSE Of- DEATH in phiin tcrmM, thiit it m:iy he properly clussified. The "Special Information" ?or p«r-
Bon* clyin^ nwny from home kIiouKI be |ii%en in every inHtnnce.
I
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Hi
■•T'4>^
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I.I
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WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
r ttt»itft=i* ?^v ;- ^'x;^
fJ^SSlfe*,
us. i> r«
ncfcn ff\ B A /^ ly /\ n ^ e- BiPi ■••/% *^r p/N B I lu o^Bi ■/*^i /^ i^i ^
IfJCi
Deputy Health Officer
Bogistered J\^o,
11?9
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
No,
h
. 0
Certificate of H)eatb
PLACE OF DEATH: — County ofO<X>^ OAXX/^vc^C/toCity of Clcx^ru vJ AXX/-^A^<u.A.ac
X/v/T^x<X/v^
'^
(y <u \aX<
St.;
-Dist*; bet.
__ .^^^
(IF DEATH OCCU RS A
\r DEATH OCCURF
WAY Ifrom usual residence give facts called for under "spe
RED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STRE
CIAL INFORMATION" \
ET AND NUMBER. /
FULL NAME
\
<lDUTY\JUi
PERSONAL AND STATISTICAL PARTICULARS
-^J-x A A I coi.ok
MEDICAL CERTIFICATE OF DEATH
DATK Ol" DHATII
\'\ 1. «>i i!ik in
\».i-:
<^
MoiitH*
(iJav) (Viar)
ai
) Vi; /
11
M.nilfis
w
/ ',/ 1 >
SI\«-.I,K. MARK n: I)
WIDOWKI) (»K DlVi »K»}:i)
(Wiitiiu smial ilt>.i;.7nati<)ii )
luk riM'i. \ri-:
(State iir I'lmntrv '
NAM I' (tl-
FAl Ill.R
ItIR lllI'l.AiK
<>!• I A rill': R
'State or Tomitrv)
MAIDI-.N NAMH
til- MoTMKR
lURTlIIM.Al'K
OF MOTIIKR
'State or (.'oiintrvt
OCCn-ATlON (JT*
igo'K
(Month) ^ (Day) (Year)
I UIvRI'HV C1;RTIFV, That I atteiickMl dect-ascd from
LAc^MI)! IC) H)oH to IXaw/^XI^ X'2>. 190H
that I last saw li ^ *•> aUvo 011 vA-^^^^^Ol -^'^ 190 '\
atuLthat (Icatli occntrrcd, 011 the dati- stated above, at I- vO
5
0^'
:\I. The CArSI{ OF 1)1«:AT1I was as follows:
0 XA/lA.Jl'V.OA.xi^ Or
J?^>-«.>V
DC RATION Years Mouths W Days Hours
CCINTRUH'TORV oU CtvJIhuL A..^^
DTRATION
)'rars ^^ouths > Days ^^ //our^
%
^-^^ M.D.
h'fiilnl III Si!u I
nil isrn
)V•,7;^ M,<lllll< b /''">
(SIGNED) VliL. 0. obo-jOkA.
LtLVA,.Qw\ u)oH (Address) U
^
JlAywv<X/vu
i
SPECIAL Information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from liome.
for-nf^or ,u:^f^Y? ^T^ Howlonqat
Usual Residence IH l3.~ 1^ Kh\, O,
>^ Place of r)eatli? ^ .. Days
I" 111'. AMOVE ST ATI", I) I'KRSONAI, 1' \ K T It ' r I . \ K "^ A K I '. 1" K I }â– . Id 111 I"!
IIHST Ol- MV K\i >\\ i.i;i)C. K AM) Hl.IJl.l-
(h
'f""'':"'t \J iV/OvaXXn^o^ Vj . J
JLa.,^^vv\-/CU'Wj
Ob Ch<i>U^'fcxx.l.
Wlien was diseaf*" contracted,
If not at place of death ?
I'l.ACH Ol- HTRIAI. OK REMoVAl.
DATl'.of HruiAi, or RHMOVAI,
im.i;rtaki-:r AD oJu1jU:L ^^ \Lo
(Ad<lrtss S..*i.^. \JM-A>«_A^V.^^V ajt
N. B. Kvery item c.lf inV'ormHtion Hhotilil h.- cnrefiilly Hupplie.l. AGfi Hhoiild be stateil F.XACTLY. PHYSICIANS should
Btntc CAUSK 01- DEATH in plnin terms, that it mjiy be properly clasHified. The "Special information'* for p»r-
«on« dyinj^ nway from home fthould be given in every instance.
!l
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If
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
II. .;nn I iT Tfcrt ttH -" P ?»«X; > ^ ^"siss
.itgssa^t^
XtS. U (*^
• •«» •
Mvt«B-e» fr\ BkAAW <%» /% mnPI »l/^ « Y'V V/%S I Al »1PBI l/^'Vl^ai *
Dfffp /v/^^^/, Uoouo^^^ an ^^6^H
Register'ed J^o,
1180
No.
/\H^i Deputy Health OfTicer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
( xa. S. StanC»ar^ )
PLACE OF DEATH; — County of 0/Ol^'>\; 0 AyOo^ruCA^^LOiCity of Oo/TX^ 0 AxX/^tlXI-c^Oo
b^ OxtoK; St.; \ Dist.!bct. OvD ^^A^A/Cnr\' and VDaA-H/OlxwI
â– n
0
Dist.;bct. OAD (QA;vAA/Cnr\' and \UAa.
(ir d^Vth occuns away from USUAL RESIDENCE give facts called for under "special information" \
IFi^CATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
)
FULL NAME
^i.j<:r\.
PERSONAL AND STATISTICAL PARTICULARS
^j;\
L
Col.oK
MATi: »)» lllK IM
A<.K
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATH ^
Mouth*
I O J,„,>
( I>.-i V )
M.inl/is
.'V«-:ir)
Da 1 .V
•^INi.l.K. MAKKIKl)
UIDOWKI) OK DIVoKCKr)
UTit« in v.xi.il fh-^ifiKitiuu)
lUkTm'i.AOK
(Statt' i)r Coiiiitr\
N^MK Of
JATMI.K
Y
(Month)
,13...
(Day)
(Year)
I UKRICHV CJvRTIFV, That I atteiided (Icceased from
r^
that I last saw h-^i^ alive on
to
.%.% 190 H
vAA-^V^ 'A.'d 190 'i
an<l that death occurred, on the date stated above, at 11 HS^.
LL M. The CAISK OF DIvATH was as follows:
xuU^.
\'\.^y^Yy\JXJii
<r^^.
^yy^
dL
HlkTin'l.AOK
ni- lATMHk
state or (."oiiiiti v>
MAIDKN NAMK
OF MOTHKK
iukthpuacf:
<»»• MOTIIHR
'statf or Coiuitrv)
M Cri>ATlf)N
f^'fsuifd in Sun /'i mtrisro \ ]V(ii < ^ y/nnf/r-
Dl' RATION }'ears Months Days
CONTRIIU'TORY LL^XXJUvo^r:v-\-Ow
Hours
crw^crv^- .
\. '
DURATION
(SIGNED)
LLlux X^. 190 'i
)'cays Months Days
I/ours
M.D.
(Address)
T6\ i(^U^^ at
/><n
IHH
Tin: AHOVE STATf:I) FHRSONAI. par TICri.AKS AK1-: TRIK JO
BF.ST OF MY 'xXOWI.KIKVK AM) HKI.IKF
(Add
ress
SPECiAL Information only for HosplUls, Institutjoiis, Transients,
or Recrnt Residrnts, and persons dying away from fiomr.
Formfr or ^ ^1 How Jon^ at
Usual RfsldfncfU<X/>v 0 AXXyYvC va CU; |»life of Deatfi? Days
Wlien was disease contracted,
If not at place of deatfi ?
PLACE OF lUKIAI. OK REMoVAI, I DATEof Bt kiai. or REMOVAI.
UNDE RTA K E rM I L 0 /(XdldUZ/Vu M iV VU AJUXAJbu ^ OAJLitV
(Address U/'i.l M rU><LA>^^trYv.3.±.
N. B..
of information should be carefully supplied. AGE should b« stated EXACTLY. PHYSICIANS should
E OF DEATH in plain terms, that it may be properly classified. The "Special Information" fsr |»«r-
-Every item
•tate CAUSE i3V DtATH In p
ffons dyin4 away from home should be ^iven in every instance.
n
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1:
I
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^;'
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WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
9 9-^„ f»W->^-tJ ^Ji»- ♦■«-
1 I f. it I ( *( • . *•'. • ^
UR, P C'n
Br-PCB T<^ B A r« U /%C" /^ C BTI l•l/^ ATr" C/^ D I lU 6 ▼ B I I /^"Tl /MU C»
/yr//r /v/^^/, Uaa^XVU^^ an ^^t'H
Deputy Health Oflflcer
Registej'ed J^'^o,
1181
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( Vi. S. StanOar? )
%
PLACE OF DEATH: — County of Cl/Oy^o; J-Vay>\yCAwA/ac City o{^ <X/y\j 0 A^CL/^-LA^oi^ tio
(ir DCATH 0(
IF DEATH
xCi.;
CMl|\J^'i
Dist.; bet.
and
ccuns A\MAV FMOM U S U A Li R E S I D E NC E Gi vE facts called for under "special INFORMAT
OCCURRED IN lA HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBE
ION" N
R. J
FULL NAME MKJlJ
. U KXX CU.
PERSONAL AND STATISTICAL PARTICULARS
' VI 1-; <»i- itiKin
Ai .1-:
31
J V(f i
1
\
n:iv>
.}/.»//// ^
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATH
X\
Pit 1>
--!\' \.V. M,\RkIi:i),
\\ llx i\\i;i) OK DlVoRCHI)
'U'iit( ill social (ksi).Mi;iti'>ii)
lUU lin'l.Ai'K
t State or fotiiitrv
K\Ju6^
%
<XyY\) 0 A/Olx>'-v'C..<^aalxo
WMi- or
I- ATIII-R
I!IK IHI'LAiH
f>f I ATHKR
'Stat< Ml roimtrv
MAIDI.N NAMI-;
<>l- MnTMHK
"} M<>rm':K
'Stat( or roimtrvl
.0.
A^OA^^A.
VUJ^A^
Vl^"vOL
(Month) rt (Day) (Year)
I lII'RICnV CI-RTIFV, That I attciKkd dcivascMl from
~- — ~ " 1 90 to -rr--—— —————— — Kp â–
that T last saw h :'^^ alive on " — ~" t<>o
and (hat death occurred, on the date stated above, at ~~
JM. The CAUSI-: OI' DIvATII was as follows:
J WcJk ^^^^ (K^JL'^'vv<>^^AJk<^^^ cLajuL Xo
nr RATION )'cars A/ouNis
CONTRIIU'TORV v^V^^^VK^.^^v'i^
Days
Hours
nr RAT ION Years Mouths Pays Hours
(SIGNED ) Ur\Xr>Jlhjl\^.u).XiU^ M.D.
">■*■' r\Ti<»N ((O
0 JL<X./W^.^ Aji J^J
'v/cL
l^Tgo H (Address) Ut\.Crv\X^^ Wl-U-^L.
SPECFAL Information only for Hospitals, InsmuWoWs, Transients,
or Recent Residents, and persons dying away from fiome.
Former or U ^ c- i> 4- y ~A j ^®**' '®"*l ^^
Usual Residence V V >i ^ O vLK CJX Plare of Dea
Deatfi?
Days
K'^siilfd in Siiii /'i nil, /',i> 0I )>(M'
M,nilJi^ — Day
HI AHOVK SIAri:i) I'KKSONAI, I'A K T lO f F, A R S .\RI'. IK IK It) TIIK
Hi-.M'oi- MY k.\<»\vm;i)c.i.; and iu-imi-.k
'Illfi>ini;itlt
-^
K/o^y^LJ^
(\<i(i
ress
lOH'5. UkAAAytJL dl
When was disease contracted,
If not at place of deatli?
ri.ACH <»!■lURIAI, OK KKMOVAI,
DATlvof IJrkrAi, or KHMoVAI,
fAd(h-css %F\ U<X/VX7 VrVjuLi; SjsA>rr^v.
N. R.
-Hvery item of information should he cnrefiilly supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for p«r-
Bons dyin^ away from home should be ^iven in ^\(»ry instance.
'; %
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M
1
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1 1
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**'-'^'**
'1- • •-
fm^
xAZ'i
1
111
III
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
i ; . i,!ttr--t* N».t- , >i::sr
i^ ii«r i» r
â– rrro yrs narM nv r.pnTirir.ATr rnn iNftTnumnNfi
/)(f/(' FiJod ,
L^
<Lfc ^H
2fJ0\
Registered J\'*o,
1188
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Death
( "Q. S. StanDar^ )
PLACE OF DEATH: — County ef
;ity ofU).d. Uj. J. dJkjAAxLo.Av
No. X/>\j .\AtO
Xltc
"?i
ex. >X\.^<X'
St.;
Dist.; bet.
and
r DEATH OCCURS AW*V FROM USUAL R E S I D E NC E G I VC rACTS
(ir DEATH OCCURS AW
IF DEATH OCCURRC
O IN A HOSPITAL OR INSTITUTION GIVE I
FULL NAME
O
JL^:
PERSONAL AND STATISTICAL PARTICULARS
j COI.OR \ P|
I oi r.iKrii
VL^
()v
TS CALLED FOR UNDER "SPECIAL INFORMATION" "X
TS NAME INSTEAD OF STREET AND NUMBER. /
)^x
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH r\
LLv^i
MDiith)
\:
O d\ Viiu
s
a)av)
Motitin
iVt-ar)
Da 1 -v
-:\t.l,K MARKIKl).
\\n><»\\Ki> OK i)i\()Rri:i)
'\Vrit< ill s.H-i:(l (U sii.^ti:iti«m)
(St.itf or Coiititrv
?
\ WW OI
I \iiii:r
HIKTlII'I.AtK
OI" l-AIMKR
^tatr or I'oiintrv
MAIIU-.N NAMK
Of MorHKR
Hlk IHIM.Al-K
Of MOTHHR
"^t.itr or Comitrv)
(Year)
.1.3...
(Month) K (Day)
1 HHRI':HV ClvRTIFV, That I attended (let cased from
to
that I last saw h
TgO
"" alive on
190
190
and that death occurred, on the date stated above, at
M. The CAl'SH C)l- DIvATII was^as follows:
DC RATION Years
CONTRIIH'TORY
Mouihs
Days
Hours
M
"^'^T PAT ION J( 5
I\[onths
Days
Hours
M.D.
DURATION Years
(SIGNED) UJ.Vk.
ULuvXt, JH iQo't (A(l(lress)U..^.U., J. ajKjL\A.xLa^x
EC^AL Information only for Hospitals, Institullons, Transients,
SPE
or Recent Residents, and persons dying away from liome
Kfsidfd III St! n J'l ii iti i^i'o
) 'lUI I .
}/»nf/ls
/hivs
1 MI, AROVK STATi:i) PKRSONAI. TAR fHTLARS ARK TRIK T« > THK
IJKST UK MY KNOWl.KDC.K AND HHMHF
(\4Hn!4.s
CU\h\^
Former or
Usual Residence
Wlien was disease contracted,
If not at place of death?
Hew long ai
Place of Death ?
Days
PXACEpi' lURIAI, OR Rl'MOVAI, j DATKof ntRtAl- or RKMOYAI,
LL-^^ ^H 190 H
IJL IQl
INDKRTAKKR
(Ad<lrcss
N. B. Every item o? informatJon should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
•tate CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for |»«r-
«on« dyin^ away from home should be ^iven in •very instance.
I'
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^
w
RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
i;, , I rit nt ricti tt i»
'*ittT^.'
^. •^.Eofln.Xi- ufi- 1> (\^
RrrPR TO RACK OP CFRTIFICATE FOR INSTRUCTIONS
HegLste/'ed JVo,
1183
\A.KA
/)a/r n/('d, [hu^xx^^ IH l^W\
d^xr^Aj^ Deputy Heslth Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
PLACE OF DEATH; — County of 0.^X4.>A,C City of 0 ^OLA^^^a^
No.-
(ir DEATH OCCURS AW»Y FROM
IF DEATH OCCURRED IN A H(
St.;
Dist.; bet.
and
IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I VE FACT
lOSPITAL OR INSTITUTION GIVE I
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
TS CALLED FOR UNDER "SPECIAL INFORMATION" \
TS NAME INSTEAD OF STREET AND NUMBER. /
. i *'l lilK 111
L
W\Xx
M..ntlil
\' v.
(I):iv)
M.mHi
(Year)
/'.n
-' 1.1. MARK ii:n
\\"Mt< in '^iici;il <1< "-ii' n;it ion)
niK III I'l. \ri-;
I" AT Hi; K
ItlKlIIlM.XrK
oi' 1 xriii-.K
MAII)|:n NAM}.
'•I MoTIIKk
l:iK IHl'l.Al'K
"I MOTHKK
'St;it< or Couiitrv)
•HiTl'ATloN
Wo<j\j^<j^<L
t
CK<LL>crru
f'K
<XA-^
%
y\j 0 >^^xa^*^aaXu
C
O^ vaxL
K^^-\^^
L
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATII /H
(Month) jf (Day) (Year)
I HI':R1':I5V CI^RTIFV, That r attcMKkd (Iccoased fruni
â– 190 to 190 "
that I hist saw h alive on 1()0
and that death occurred, on the <h»te state<l above, at
M. The CATSIv UF DlvATII was as follows
i'^
^^O^y^
A^cX^-vj Cr
I*
A_iUX^,
1-,
DIR.ATION )'ears
CONTRinrTORV
Months
/\iys
Hours
nr RAT ION ^rfe''^/-^ ^font/is
LO J. vDaaaJ^/^
Days
Hours
(SIGNED )
rwcL
Kffiiifd III Still /'i iini isi'ii
)'t<ii
.}/''ii//i^
/)./!.
rni: xnovK staii-.i) pkksonai, iv\k luri.AKS aki. rKiK ro tin-:
in-:sr 01' my KN'i)\vi,i:i)(.K am> Hi-j^n:F
'Infi>tin:n\t
ULcn^-ojLMjti>j o
/'O
-(Addn--^
(^ \]
M.D.
X}^ iqo'l (Adtlress) .. J .\JUl^^.^ V^<xL
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
Former or
Usual Residence
When was diseaje contracted,
If not at place of deatli ?
Hew lonq at
Place of Oeatti ?
... Days
ri.ACH ni" lUKIAI, OR RKMOVAI,
DA 11; of Ml KIAI, or RKMOV-Al,
LLc^Ki, ;i.H 190H
INDI-.RTAKl'.R
Ad.lie>*s 3>IH U 0 .<X/\J\JUUL». .3.1
N. B.-
-F.%ery item of Information should be ciirefuliy supplied. AGF. should be stated F.XACTLY. PHYSICIANS should
Htate CAUSF: OF DFATH in plain terms, that it may be properly classified. The "Special Information" for per-
sons dyin£ away from home should be feiven in every instance.
ilu^
' I
â– .,T;
â– <. I'
Mi
I ^
t .
H^i
i
/ i J "
I i . ^ t^
'5
â–
1
(ii;l
1 1
I
â– !
mtTiOL
fe^-
i/W*
I
w
RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I;,,,p! ..f n.nllh 1 V.) !-^ l^-'-^^^^-nfcVCo
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
JReglstered J\^o,
1184
Duir Filrd. [Xj^j^^O^^^^j^ V\ 100\
Xc-i^vo "cL/v-u Deputy Health omcer
DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of 2)eath
( *a. S. StanC>arC> )
%
PLACE OF DEATH: — County of^<X.^^r^ J-ZuOL/TV^eAAcCity ofO/CLA^ 0 >^wy(X^vA./Ti^v^<i^<^0
No. \H 0-C'CV-K^^
St«; 3v Dist.; bet.
(
ir Dt*TH OCfCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FO
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME I
i
and CJAwXX/rJj
â– OR UNDER "special INFORMATION" "X
NSTEAD OF STREfT AND NUMBER. /
FULL NAME
•^i:.\
\)V\'\-. «)1- 111 KIM
\' . I-:
PERSONAL AND STATISTICAL PARTICULARS
I COI.OK
-^yvA^'
u
as-
(Day)
Aw
I Vtai )
b^ )v.„« 1
Mi»ilJis
x\
MEDICAL CERTIFICATE OF DEATH
DATK (>!• I)1;a TH r
[Day)
190 ';
ihi
^ivc.i.i-:. MAKkii:i)
\\ ii><)\vi:i) <>K i)i\<)KrKn
Wiitriii voria! <lisii.Mia( i< »ii )
AxL<5-\A>-OcL
lUK riii'i, \ri.;
(Stall '(I I'liiniti \ '
NAM}-: or
I A 11 11: R
iMKriii'i. Aci-:
<)i- i-Aini-:k
'Slate or C'diiiill V'
MAini.N- XAMK
t»i- Morm-.K
liiui'm'i.Ari-;
<>!• MoTHKk
'Slate or Cou!itr\-^
ncMi'AiioN r\
/\'rs idr,
C^^X<^>^J
'tr'^Ar^^'
(Moiitli) I (Day) (Year^
I{Kl':nV CI'RTII'V, That I attended dcivascd from
0^ IgoH to LLCV/CU ^^ T{)oH
n T
tliat I last saw h •*- ' -v alive on vAXaxX, 'X.l Kp '\
and that diatli occurred, on the date stated above, at b lO
VJ M. The CAlSlv ()1< DI'ATIl was as follows:
LJKa^^>-^,a_^ CVy>Ztje.Aw<jtAjIX<\X) Vi ULAAJk/'uCtX-'^
DC RAT ION % Years Mouths Days Hours
CONTkllU'TORV XXjXj^XJLry^nK,*./^ L<«:rY»,
rV<CV-
Dl'RATlON
)'rars
.^fout/i}
/hiVS
V^'utrVAKw
/â– 'i il III I til I )V,/;k ,i^ y/,iiifh^
_ _^ - - -.... Hours
(SIGNED) X . V;. \I)\eyv\xJLXA M.D.
XH Tc)oH (A.ldress)S.lH% ViK^UKcUa.^ cSi
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from fiome.
/Jm
111 I'. \M()\1.: sr \ li;i» I'KRsoN \1, l'\K Ih I I. \Ks AR 1". I" K T K. To Till-;
Hi;sT <)|.- Mv K Nowi,i;i)(*,K AND iu;iji;i-"
till
r %.^ Q>^ (k= 1..
<:x_
u-id
re-"^
IH
•XjOJ^^aj^
ix
Former or
Usual Residence
Wlien was disease contracted.
If not at place of deatti ?
How lonq at
Place of Oeatli ?
Days
I'l.ACl-: ()!• HIKIAI, OK KlvMoVAI,
rNDi;K TAKI'.K
'Addrrss
DATi:.)!" l!riM.\i, or KJiMoVAl,
CU^ an i9o*H
^- **• livery item otf int'ormjitioii Hhotihl 1).- cnrcfully Hiipplieil. Adli shfiiild be Htnted EXACTLY. PHYSICIANS nhoultl
Htiitc CAlJSn OP DKATH in pliiin tcrniH, thut it miiy he properly claHNified. The "SpeciHl Informntion" for par-
dons dyinjt tk^Nny from home Hh<tiiltl be ^iven in every inHtance.
>ri
41
<
-
j:
Jf
' ;
» ' I •
.\ â– ' ,
â– ''\
I'lr
! I
!l
11
i
â– '(
ISJ
ji
» »
m»
mm.
I
' :!'
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
•»^
,U.anl M- II.Mltl. - I- N'o. I^ -fr-Ei^K^ I5«^'' ^'
REFER TO BACK OP CERTIFICATE FOR IIM3TRUCTION3
XJvK^ Deputy Health Officer
Regi\stcre(l J\^o,
1185
CV'Cr^-A.vo
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Death
( XX. S. StanC»arO )
of Ooo^r^ 0;\^/OL/V\X^VXtCoCity of 0/CL/TV OXO^y^O/C^LXi^^U)
PLACE OF DEATH: — County
No.
OoLo^ajlUv^
^OM-
St.
0 Dist.:bct.
and
/ \r DtATM OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" "\
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
:-)
FULL NAME
cu
r\Al.^
PERSONAL AND STATISTICAL PARTICULARS
SKX (K\ f\ I COI^OR
A'\^^'
t^
l»\l K <i| lUKIH
Al'.K
ID
D.tvl
rv.-ar)
)â– -,/. .
1/,..////.
bJ
/',;^.-
WinnWKI) OK ItIV( »Kri:i>
Wiitriii v(H-i.'il (lr^i;'iiati'>ii)
xj^\y<x.
HIk rui'I.AOK
'Statf (ir Coiiiiti \ t
N \Mi; Ol
I- A 11 1 i:r
HlKTnri.AfK
OI" l-ATHHK
'State «ir CoiiTitrv'
MAIDKN NAMH
<)l- MOTHHR
IMRTHl'LAOK
<»f- MOTMKK
(Statf or (.'(innttvi
1' 'Tl' \TI< >N
/\f\u!f<i in Silll ]'i i\ )i, n,-<i
X
Jj Q^
<^c '^ ^.
) "v. I V
X )
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATH
(Day)
l9o\
(Year)
I III':K1<:HV certify, That I attemlcd ilcceased from
XCi iQoH to LAwA^v^ Xl ...._. TOO H
that I last saw li-*!-'^' alive on vAaa-O, VvO 190H
and that death occurred, on the date stated above, at I X
^-' M. The CAl'Sli t)l' DlCATIl was as follows:
\/W\j
cJ-u^t^-^stj.
Ur RAT ION
wo„C
\
â– ^JLO
Years Months
CONTRIHUTORV AxaM/cL c^j^^G:v^l. k).....r
Days t) Hours
nr RATION
(SiG
Years
Mi>uths
Pavs
) .
in. \HO\K ST ATI" I) I'KKsoN M, I'A R lUT l, \ R «, \Ki;
Hi-.sT ni- MA- KNti\vi.i-:i)(". H AND ni-:i,n:!"
Rfi". I'l > Til)-;
IiifoMiiritit
V
/CXX>uo-\j ujULoj-
NED) \J lU<X>\ju LI- JJ/0^^vXX^^^
LL^^n %[ icpH (Address) '^ H Vb A^tKtx, rL c) i
Hours
M.D.
^
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
former or
Usual Residence
When was disease contracted,
If not at place of death ?
How lonq at
Place of Death ?
Days
I'LACl-: 01 lURIAI, OR ki;M<)\ \l. I I)\ri;of Mikiai, (ji RKMo\AI,
iNDHRTAK i:r \J /oJuLAaAJL VI lvCXAA.^r\jo ^ yo
>>• K. Every item oH* Information should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CADSK OP DEATH in phiin terms, that it may be prf»perly classified. The "Special Information" for per-
sons djing away Vrom home should be Jiiven in every instance.
<:.
< .
i
(Nl
i ! .
%
V j
t
I
'(
i*i
^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
H<i:it'l I'f H
I, ,1th |- No n -S^^^j^H&J'Co
REFER TO BACK OP CERTIFICATE FOR IN3TRUCTI0N3
Ihife Filed,. \hj<x>^^ V\ iOCn
Registered J^o,
il86
X^
AjLA^ dL.^M.| Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( tl. S. StnnDar? )
PLACE OF DEATH: — County
No. 11 \ft CrvL>vlvtrvv. VJ Xcxc^^
Si ^ ^ ^
ofCloo^YAj JxxX/\^cu_xi.c.cCity ofOO-/^^ '-
St.; ^> Dist.;bct. cLiv^ otj^ and ^^^jlt^^'L aXj>.. )
(ir DEATH OCCUnS AWAY FROM USUAL R E S I D E NC E Gl V E facts called for under "special INFORMATION" '\
IF DEATH OCCURRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
0^
si:\
IiAlK ol lUKTU
CO I, OR
VA>jtj.
0^
(Month)
\<.K
1\
\'( o>
10
tl)ay>
M,»iths
(Yf-ar)
MEDICAL CERTIFICATE OF DEATH
DATK ()!•■DKATH
(Month)
Ao igo \
(Day) (Year)
Da \s
^INC. !,K. MARKIKI).
\Vint»U}.:i) OK I)IV«)Ki'KI>
'W'litt in siMJal <U"iivnati<>n)
HIK rnj'I.Al'K
'Stair or Country^
NAMK 0|-
FA IMliK
HIK'niPI.AOK
ni- FATHKR
(State or Couiitrv)
UAxiOk) U oVxxL
MAIDKN NAM1-:
UI- MOTHKR
IHKTHPLACK
<M- MOTUHR
(Statv or Country)
OCCl
€cA^vxl_
v->v^
>-u
I HHRI':HV CIvRTIFV, That I atteiKlcd dec cased from
V- I 190'i to LLla^...CL3 190 H
that I last saw h r^^ alive on
and that death occurred, on the date stated above, at IC) oO
CL^M. Tlie CAISK^)!' DIvATII was as follows:
^Ud
"VA-XiyW)
DC RAT I ON Yeaxs ^ Months
CONTRIBUTORY _
DURATION ^ Years MontJis
Days
Hours
Jt/>A-A.^\AJA^<X.
Days
(Signed)
cCa^^^v
Hours
M.D.
:crpATioN (7i j a
Rfsidfd in San /'laiitisrit X I )V<f>.v \^ Munlhs \ /htvs
THK AnoVE STATi:i) l»KRSONAl, I'AR IKM" LARS AR1-: TRrK To THK
RKST or MY KNOWI.KIX'.K AND HKMKK
(Informant
Vv^ U
( Vddrcss
5vl ViD crvuNj(j-tr>v VJX(X
^x
<N
^^ i()oH (.
Address) ^^^ D'ar^^rljUA. \X\<L
SPEOIAL Information only for Hospitals, institutions, Transients,
or Recent Residents, and persons dying away from liome.
Former or
Usual Residence
Wtien was disease contracted,
If not at place of deatli?
How long at
Place of Death?
Days
ri^CE OK BIRIAI, OR RKMOYAI, I DATKof lirRlAI. or REMOVAI,
INDERTAKER VI I I Kjj^/y\y^r\, ^^>y^^-<l>
(A<Mress 'kX\ QfYl^ QULLx^Ix^, ..^X.
U-V\^ ^.^ i9o'\
!^. B. Every Item of informRtion should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for psr-
sons dylnft away from home should be ^iven in every instance.
r
r. ,<
'.
i*l
111
n
=1
*»feStt"
iPilA
-JMIfcP»-
"^i^
tZ. iT"-;
i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTfONS
1187
n ,..,,.1 uf Hf;ilth-I- No. i^ l^!*?^"' i^^^' ^<>
Ihffr FiIe<L LL>^.Q^>cAt XH ^'>6> H
iL^K-^owi "Ix/vKH Deputy Health Officer
Rcglstei'cd J\^o,
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of 5)eatb
( TX. S. Stan^arD )
J? Qi) tX ^
PLACE OF DEATH: — County oi^OuY\j 0 XXL^vo^^.^City of O.CL/^v 0 7vCXa^^^^^-c
I^. vj o^OoVv^-
CkAxaJLoJ;
St.;
Dist.; bet*
and
— - )
r OE*TH OCCUnb away from USUAL RESIDENCE GIVE facts called for under 'special INFORMATION" \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME
/OAJU-XT \J/OJv^(5- Y\^J
PERSONAL AND STATISTICAL PARTICULARS
Si:\ A - A I Cf)I,«»R
I> \ TK ()» I'.IK'IH
CL
M.mth
a(;f.
1!?
il):i\i ^Vtar)
/\'h-
Ti
)-.<:
M.-tiHn
Pd \s
<IN<".I,K. MARKIi:!).
WIDdWKI) (»K DIVoRvHI)
'Wiitt in ><<Ki;il (1< siv:ti!iti<)ii)
lUKTUPLACK
(State- or Coimtrv^
NAM!-: OI
I ATHKR
TUR'IIIPI.ACK
0|- I- ATHKR
' Statf or Cmintrv^
maii)i:n nam I".
<>1 MOTHKK
HIKTHI'LACK
<»l MOTUKR
i State or Coiintrvi
1«
\i
MEDICAL CERTIFICATE OF DEATH
DATR OF DKAT
â– " CL
(Month) A
'Day) (Year)
I Hl'KI'liV CI'RTIFV. Tliat I aUeiukMl dcct-ased from
N^i^uLu IH 190M t() ...Lm^^^.....2^2). 190 'i
tliat^I last saw h-^- alive on lA.A./i./CV '^'^ 190 ^
and that ik-alli occurreil, on the date stated above, at b XC
Vj M. ^he CAISI*: Ol- DI-ATII was as follows:
r"
DT RAT ION Years,
CONTRIIUTORV
Months Days
Hours
â– \
DURATION
(SIGNED )
Years
Months
Pa \s
X
>^ )r^
Hours
M.D.
OCCUPATION
^'V.XXXW'
f\''.:ded III Still ritiin/M'i} v..) ) i<i i
M'lith^
l>,:\:
rm-: ahovf, STAfKn i-krsonai, rxRTiccLARs aki-: tkik
Hi:ST OI- MY KN0\\M:1)C. K AND nivI.IKF
TO TH1-:
'Itiforinaiit
Addr.^^s) ^Hi oxvtix^. d;l
SPEOIAL Information only fur Hospitdls, institutions, Transients,
or Recent Residents, and persons dying away from liome.
Former or A'T . i; it \ < "»>» 'o"? at
Usual Residence lb(Xb v 0.
b lb Vj d <XX\JLLI ) t Place of Deatli ?
Days
Wlien was disease contracted,
If not at place of deatli?
ri.ACK Ol- lURIAL OR RKMoVAK
DA Ti: of IJiKiAi- or KFMOVAI,
rNDi:RTAKKR V V "J \AXaa^ n ^^
190
'Address
N. B. Every Item of Information should be cnrefully Hupplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for per-
sons dyin^ away from home should be feiven in every instance.
♦ I
i:
: i
i'i
, I
'111
,l
(:•:
m
^^'
f
i]
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
,,„,.,,.lof U.-AHh- I- No !^ l^^ao^hS^VCu
I 1
I)fff(' Fih*(l ,
an
100 \
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
1188
Jf,eo^Lsle/'cd J\^o.
dUrvA^^ doi^v-M. Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccttificate of Death
( xa. S. StanDarC> )
(^
PLACE OF
DEATH: — County ofC)/Ov*Y\J J A.Oi/'A-^^AA.ocCity oiO<Xyy\j O/uo^-v/CA^c^i
No I b H I 0 1) Cy^^XX^vA St.; S Dist.; bet. ^ ^ XJk and 1 ?^
/ ir DtATM OCCURS AW»Y TROM USUAL R E S I D E NC E Gl VE FACTS CALLED rOR UNDER '•PtCIAL INFORMATION- \
V IF DEATH OCCURRED IN A HOSPITAt OR INSTITUTION GIVE ITS NAME INSTEAD OF STBEET AND NUMBER. /
|\J
FULL NAME
./QJL^W^.y^^<YC{ry\) U/UcLcf\j
<^^UL
PERSONAL AND STATISTICAL PARTICULARS
I
[jjJrjJuL
i)\ri-; <)!• mRfii
vH
oL)xc-
^0
>M<)tith)
<I)!«y)
(Vfiir)
\ ' . K
S^
]'itt I
1
Mnnth^
ao.
/)</ r.v
'^IN<".I,K. MARKIKI>.
WIDOWKI) OK I)IV(>RCKt>
(Uiiltin '"ooial (lisi).Mi;it ion )
HIKTmM.AOK
i Statf or (.'f)nnti"V^
<XAA.OL/cL
iat!ii:k
lUK IHri,\CK
0|- lATIIKR
'St:itt or Tomitrv^
MAIDKN NAMK
OF MOTHKR
lURTHl'I.ACK
<>l MOTMKR
(Stale or Couiilr\ i
^^Crv^XTTU
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH /O
(Mouth) \
(Day) (Year)
X III",
.^J 10 190 H to
that I last saw h a^>> ^ alive on
I UKRICUY CIvKTIFV, That I atteiuleil deceased from
LLxA-XX. ..^\ IqoH
Uaa^ QlV 190 S
and that death occurred, on the date stated a])nve, at ^
J M. The CArSH OF Dl-ATII was as follows:
\| I Uwy(KCL^OLA>Xx.A-AA^ /Ol/vwcL. C/ <
,03^i-<cd .Aj^JUt
rVA./CU>&->^VA\JiXjLVw:tJ..
1)1' RATION
Years H Months II Days
â– I
CONTR inrTOR V UL>L(KA,orrvA/\\.*jJv-s- OV JVvd^^JiA.
(^
occv
l\/-iilr(l lit Sou /'iiiuii rn cn i, )'.//^
\/,',ith<
/>.n
rm-: ahovf: stati-:!) rKRsoxAi, i-aktuti. aks aki-: tkif: to rin-;
l!i:sT ()!.• MV KNOWI.I'I )(".»-: AND III-:!,!};!'
h
itoMMant \| ^LoJV^^ O^^XyrCfc vIXv^uC.
r\(i.i
rrss
1)1' RATION r^ y'orrs Months Pays
J. \l RxX^LA_A^^JL^ . M.D.
Hours
t
/fours
(SIGNED) ^ -'>n
LLu\ a?) u^oU (Address) ^ OO" U^^-VaMaX OJ
eS
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
Former or
llsudi Residence
When was disease contracted,
If not at place of 'leatli?
How long at
Place of Death ?
Days
ri.ACH OF" Hl'RIAU OK KKMoVAI, I DA TF! of MriuAi. or KKMOVAI,
(Address 15 /XH. 'OX<y^iX\Xjtryyj^ Clt
N. B. F.very item of in?orm»tlon should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may he properly classified. The "Special Information" for par-
sons dyinft away from home should l)e ftiven in every instance.
\
P: fT
'W.
f
^
.1 ;
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!•
I
. >
i
I. ( r-J
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\\\
"iiii
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f
lift
II
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WRITE PLAINLY WITH UNFADING INK —
..I II
,,„,,.. ,.• vn. ^^ ■J^S^ ^^^^' ^*"
i)((h' Filed, Uaaxl^^ an l'^0\
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
llei^istevcd J\^o. Xjlo9
/V-M D^P^^y '"^^^!*"^^ OfHcer
DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco
Cevtificate of Bcatb
( U. S. StanOarD j
(^
PLACE OF DEATH: — County of'
CU-o.' 0 .^X^,'-^^^CAAXlcC;ty of O /CVTV J X<X/->v.c^«.<^
No
. \^\\
.KJ^\
A\J^'Y^J
St.; 'I Dist; bet.
and
J .w ,»^.- iicilAI nrc; I nr NCE GIVE FACTS CALLED FOR U N D E R V S PEC I AL INFORMATlOj
( '^ rF"o;:TrOCCURrEV;N''rHO^S^VT"At rR"r;ST'.?u"o"^C.VE .XS name ..STEAO OfUtREET A.O .U.BERJ
Cj»^ )
FULL NAME
SKX
DATK «>l lUKIlI
\' .I-:
PERSONAL AND STATISTICAL PARTICULARS
I c'oi.ok
f tnlltll!
Slo
) Vim
1
(Day)
M.^nlh:-
r%h\
^
(Year)
/:>â– / is
SIN<-.I,K. MAKKn:i>
\\ii»» i\\}:i) OK i)!V(tKrj:i)
'Write in ^urial dt •»iv'ii;tti')ti )
niK'rniM.AOK
'Statf or Country)
NAM!-. <)I-
fatiii:r
Hik'nii'i.ArH
<)I- lA IMII-.K
(State <ii' Cdiititi v'
MAII)|:n NAM)-:
<)1" MorilKK
lUU Iliri.ACK
Of MOTHKK
(Stat*- or Co\nitrv^
Y^<yj
occrpATioN 0 n
h'fsided in San Fiamism 1 b )<■.);> — 1/""
///â–
iKn
Tin', AROVK STATl-:i) 1'KRSONAI. PAR TUM- LARS A R J". rRII-! l' • IMI-;
HKST OF MY KN()\VI.i:i)C.K AND lillMI'.F
(Inforniaiit
Q
(TVo
n
(Address
10 l^ ^J^^^/U^oco^jfc dl
MEDICAL CERTIFICATE OF DEATH
DATH OF DKATH /^
VwAjwAX^^ ^^ igo H
iMontli) \ 'I>:iy) (Year)
I IIl'lKI'iHV Cl'R'riI'N'. Tliat I attciKU'tl deceased from
to ———190 "
-—190 —
190
that T last saw h :: alive on
and that death occurred, on the tl.ite staled ahove, at
— — — M. The CAl'SK Ol' DI^A TH was as follows:
1)1' RAT I ON Years Months Pays Hours
CONTkimToKV ^>-. , ...: v,.^Cr:>:x...4^.'>^^..
DrRATloN".^ )'i'ars
^fofil/is
Hours
Pays
(Signed) JXX^O^l;^/^ U. KJ^jy^/yxM
LUuy'b iQoH (Address) (^ ^ ^^ . . . j) \U . .
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
^ M.D.
Former or
Usual Residence
When was disease contradfd,
If not at plareof death?
How lonq at
Place of Death? Days
ri.ACK OF" lURlAI, OR RF:M0VAI, I DATi;of III KiAl. or RKMOVAI,
l-NDHRTAKKR M l\AXAy-W jJ oVk ^Vw \^
1.ZX M lO^yCAjLCc. C)±
(Address
N. B.-
-Bvery Item of information •liould be carefully Hupplied. AGE should be stated EXACTLY PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The Special Information tor per-
sons dyin^ away from home should be ftiven in every instance.
kp'i
'1
:*
if i /a
41
Iff
WRI
TE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
lUtfr riled, CL
Wffi V Co
PiUeTiONS
^H
I'JO'A
REFER TO BACK OP CeWTIFICATC rOB IW»TBUi;Tim
li90
Registered J^o,
!lh Officer
.'v-u Deputy !'
DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco
Certificate of Death
( "a. S. StanC»arD )
PLACE OF DEATH : — County of C)<Xy-.A; 0/v-XC^»^cv4A:-oCity
%
t»
No \io'X 0(nAXJkVJ.a-^v.k St; 3 Dist; bet. ^ O^Vti and '^K.^^
^^^* ( .r oc*TH OCCURS *w*. rROM USUAL RESIDENCE eve r*CTS callco ^o" undcr ^^H^^^'^^^^^^'^H^^^;'*' )
C IF DCATH OCCURRtD IN * HOSPITAL OB INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. •
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
t
UJ^^aJjl
I»\ 11, <»l- »IK III
AC. K
^W>Jlj
iMo*it)i)
O C> iv</'> \
(Day)
Mouths
(Year)
Dii V,
SIN».|,K. MAKKIKI)
\\ innwK.n OR nivnkiKi)
iWiitc ill s<K-i;U (k»i>f nation)
HIKTMI'UACK
(Statf or C'mntry)
AxLcrVJ-
.y
> \xL
! '!
NAMK Ol
}• ATI IKK
HIR THPI.ACK
Ol' KAPHKR
iStatc or Country^
MAIDKN NAMK
Ol- MOTHKR
HIRTlirUACK
OF MoTMKR
(State or Country)
e
(^
dLou"ojv/cL 0 crlxu.
(I
AaxLouLAj ij CPrurvKX/>v
OCCIT
(aO 0-v.y^-<iJLA.A>^-|Lx
M,»ith:
fhiv.-
THK AHOVE STAri-:i) PKRSONAI. PARTICl'LARS ARK TRTK To THK
RKST OK MY KN()\Vl,Kn(^.K AM) BKIJKF
(II
(Afldress ...iJ© 'X O CTwUk
MEDICAL CERTIFICATE OF DEATH
DATK OK DKATH r\
\Saj^
(Month) a"
(Day) (Year)
I IIRRHRV CIvRTIFV, That I attended deceased from
^.IjL'IX^V' IgO . to LtM^/q^ 190 H'
190 '\
190 . to
that I last saw h -*-•' alive on LAaa^
and that death occurred, on the date stated above, at 1 1 4.5"
CL M. The CAl'SK OF I)I';ATH was as follows:
\_,/|x^v.xrrv-A>/t .\r\j^^^
Di; RATION I Years
CONTRIBUTORY
Months
Days Hours
DURATION A Years Months
Davs
(SIGNED)
190
H
i
: Address) W 5"
do y.oAJk
Hours
M.D.
SPEcVaL Information only for Hospitals, institutions, Transients,
or Recent Residents, and persons dying away from home.
'X)
Usual Residence
When was disease contracted,
If not at place of death ?
Days
PUACE OK Bl'RIAI, OR RKMOVAI,
u;
(Address 1.
DATK of m-RiAi. or REMOVAL,
A I iLvA^iA^trYV
^^
information .hould be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
5F DEATH in plain terms, that it may be properly classified. The Special Information for per-
N. B.— Every Item of
state CAUSE OF
sons dyin^ away from home should be ftlven In every instance.
( . s
II
J
fW
i: ''5
ii.j
I
I.
â– (
I Si
' ! t,'
â– \ '
$
0
]f
T
f'
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
_ .___._•>«• -^p- r-.^ry I ai ^^Tl I I /^"n <^ M O
!'.\ !â– Ci
REFER TO UACrv Uf v^cniiri»^(-»iw i v>" i .■« ^ ■> ■»> «^ ■• ^
7)/-//^ Fi/cf/,
as^
/e76>H
Jteo'i.sfe/'ed jYo.
1191
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH==City and County of San Francisco
Certificate of Beatb
( 11. 'I\ Gtan^ar^ j
PLACE OF DEATH: — County of OOr^ 0 AXX.yv^^OUL^ City of O^CX/vv 3 Axx^a_ai^^
No, HHC) a Axi/>x<yu-^
St,; I Dist.; bet.
and
iic^iiAi DCCinFNrF riUF FACTS CALLED FOR UNDER SPECIAL INFORMATION \
FULL NAME
r
PERSONAL AND STATISTICAL PARTICULARS
SI A
L
C< '1,< 'K
i. \ 11, t •! i'.lR I II
A^^kXx
Vl ftoL^v
N!..iith
( I);ivt
/ISO
> r.'ll
A I â– .I-;
5H
) . â–
w
-i\r.i,i-:, MARK ii'.n.
A iix »\\i:i) <»K i»iV(»Ki"i".n
iiiK I'll iM. \>;i':
(Sti'tc or (.â– ')nnli \
lA Til I'R
r.iinii I'l, AC}-;
0|- lAIIIKK
' St.il r 'ii r<nint 1
MAIDI'.N NAM1-:
<>1' MoTllKK
I'.IKI'UPI.Ar]',
OI- MoTHlCR
(Sl;it(;' or Co\uitryl
1
/^^/CrVAT'Vv^
•Co
OC(
^'.•' 1,1,-,! HI Sill! I'l .ni, !}(■'• O '^ )V(M
- M.nilh' - /Vn
Til I- \i!n\i.-. sr \r):i) pf rsmnau iwrtum-laks ar}", rRn-: r<> Tin-:
in'.sT ()| MV KNOW I,i:i)<".K AM) inn.ii"!''
(Illf-r luilllt
MEDICAL CERTIFICATE OF DEATH
DATl", nl I)I;aTII
I'Moiith* A
iDuy)
(Yf;irl
1 90
H
I lll'Kl-r'V CI'RTII'V, Thai I all ciuled deceased fmin
CLuL^ "^ icpH I.. ibwA^ 'X\ icpM
lliat I last saw IiA^ava alive on \Aa.,a.^ 'X'J
an<l that (Katli (leciirrcd, on tlie dale stated above, at
M. Tlu' CATSI'* (>1' |)i;.\'PII was as follows
Hours
.M . 1 in. V .
DT RAT I ON ^Yiars Mouths Dovs
/ w iv 'ri> I !>i •'rMi> \' ^Jft-wX J\/»-'^-W~
1 ) I " R A T I ( ) N
Years
Mouths
Pavs
(Signed) LxxaX^ O Oo^rrJu-tyvLc)
^k^-iqoH (Addrc^^.) ioC^l U3 <W^^^-^vClt>>^^
SPECiy^L INFORMATION 01'y '"^ Hospitals, Inslitution", Iran-
or Recent Residents, and persons dyinq away from hoiie.
I lours
M.D.
Former or
Usual Residence
When was disease contracted,
If not at place of deatfi?
How long at
Plat e of Death ?
Days
ri.AeH nl' HIRIAI, OK RICMoXAl,
NDKRTAKl'R U /CJut/^^CtX Vj /\XXA>/./VA^
fA(Mi.<- I5"XH O txK«LJ!sX<rw
DAii; of lit i.-i.\i. or ri;m<i\au
N. B.— F.very Item otf in?,>r.mnt1on Hhouhl b. cnrcfvUy supplied. AGF. Hho:.ld be stated EXACTLY PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The Spec.nl ln>ormat.;>n kor per-
sons dylnft away from home should be <*iven In every instance.
I
m
'f'.
iM
111
;
i
i
1
WRITE
PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
,,.,:,nl..tii.-:'iti, IV., :: n-v^.^; n^^l^^.,
ntrs.n i v^ u*mwn ** •
T cnn iN«»TRijr:TiONS
7,V6>H
Jien'is/cfcil ./Yo.
1192
"Su^^Ia^ Deputy Health Officer
DEPARTMENT 6f PUBLIC HEALTll=City and County of San Francisco
Certificate of Beatb
( 11. 5. StanC^nrD )
PLACE OF DEATH: — County
4
ofO^OL'^x^O/vOL/^^'v^^uiyCt City of C)/CL/>A; J;v(X/yv<^>UL.<M.^
^ Cj/CuY\.oXcV»^<St;tv Dist.;bet.
— and
/ ,F DiATH OCCURS AWAY TROW USUAL R E S I D E N C E G . V E FACTS CALLED TOR UNDER "SPECIAL 'NrORMATIO
( .VdEATH OCcJrR.D .N a hospital or institution give its name instead or STREET AND NUMBER.
N.)
FULL NAME
KAXA/-
'>^UL
®
PERSONAL AND STATISTICAL PARTICULARS
C<)I,<»K
i r \\-\:_ I li :.; 1< I'll
/oJU
^15
v\
< V ;ii
/'„-i
\\ Mm •wj-I) «>k ih\< ti", ri; f)
!i -i;.Mi.itio!i )
\j<x/d^
iUKTm'i.Ai'i-:
'St:itc or (-'oniil I \
'n- S Mi. ' >!
I '.XT II I-K
lUkTinM.ACH
" ' \rm-:R
â– 1 t'ouiilrv'
'i; Ml ''I'll i:k
isiK iiiiM, An:
Ol- Mo'rHl'.R
-â– 'i Mllit 1 \
Mcri'AiioN Qj\p
) X\yV/\XXrYV/^rv
Aa^^Xo/A'^^^^^'^^^'^
rAj
A''
/ <' S,/ J/ / '; ;/ Ih
1 â– <',//^
rni-: xhdvk st \ti-. d i'i<ksi>\"ai, rAkiuTi. \i<-. aui. tk i )•• ii » i ii i:
HKST i)l- MY KNOWl.liDC 1-; AND in;!.!!'.!
â– lllfiMlKIIlt
I
MEDICAL CERTIFICATE OF DEATH
DA Ti: (11 Dl.ATIl
Laaa.<
U)av)
(Yfiir)
T90H
MontlO K
I lll':i< I\1*>N' C1:RTI l'\', That I ;ittoii<U(l <k-(x-as«.Ml from
that I last saw h -^"^ alive on Lm^AXJ; ^'^
anil that .leatli occiirrc<l, on the date stated aliove. :i1 I 0
W M. The CWI Si-: Ol" DI'.A Til was as follows:
KCRATloN i Years Q. MdhI/is /Kiy^ Hours
l>rR.\Tl()N )â– ,<;/ V Mouths \^ Pav^ Hours
M.D.
Special INFORIVIATION only ''"^ llospifdls, institutions, Irdnsients,
or Rerfnt Residents, diid persons dyin] awd) fro-n liome.
' \J /U.-'Q^A^c^ox
. Days
Whf'n was disease fontr,)fted,
II not at plare of death?
I'l.Ari'. < »i i;t K lAi, I 'K ki:m< >\ ai.
vAJl/>w/cxi
-\.
DA'llI'. "i' !'•■i^'i \i- "1 K i■.^T' i\'AI.
(Addrt- WW ^\\\KJ^\^^.^rw ol
vij\X/aAtuL
3AJUl^rv
N. B. Rvery item ui information shouhl b.- cnrufiiHy suppliefl. AflT. s'v.ulil be stated KX4CTLY. PHYSICIANS Hhould
state C4lISr or DliATM in plain terms, that it may b.- properly clasHified. The "Special Informuti jn" for p«r-
Ronu dyin[^ away ?rom home should be ^iven in every inKtiince.
<| I
'I
( \
i;|
< I
I
-T
WRITE PLAINLY WITH UNFADING INK
THIS IS A PERMANENT RECORD
!;..;im; "I
II. .ilth - I-' N'^ :•
u^*- ■— *
_.-.. _. ^_>.i^ir.ir^>^r- r-rso llvier'TDII^TiriNi
rs" -â– -, !!N:1' *''!
REFER TO Bm^K of \^trsiiriv^/-.it>
IX«I» l<«^^t>)«l*
■ca..wiM —
/>^//r Fih'fl y VAaaxdl/u^^^ ^S'
/ryf^ys
Re^istpfcd JS'^o^
1193
(>^..<rv.A.^N-o
Deputy Healvh OfHcer
DEPARTMENT (iF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( la. 5. J^tnn^arD )
PLACE OF DEATH: — County of
— City of Oiy>x{rvoj
'No.
St.;
Dist.; bet.
—and
;
FULL NAME 0 JUCsVL'^kv Y) V.XX/v-oxy^^^'^^^
si:\
i »A 11 ' 'i i;: K I II
PEIRSONAL AND STATISTICAL PARTICULARS
M. :!Hh
\< .]•:
i^c
i .
1
â– )/ ' I'l
AS'i
â– >â– â– :il !
n
>-!\«.i.i- MAui<n:i».
WIDoWKn OK I>!\< •!• II)
liiK rm'i.\(*K
st,it( 'ir Coniitt y
I \ I II i:i<
I'.iKTniM.vci-:
<•!■1 \ rm: u
v''iiiiilr\-
M \il>i:N NAMl-:
<il MnTIM-.K
?
I'.M; llll'I, M)-,
'M M(>r!ii-:k
< I â– I â– i : I N
AV â– /,
^5 K,.-
1/ , ///
1 III- W.nV]-. S rATI-D CI- K->'>\ \l, 1' \K ri«M"r. \K!^ AKi; TK IK 1' > THi;
lU'.M" Ol M\' J;^ N( i\\ I.l'lx.l-; AM) Hl'MI'l"
Hiifo' ni.'iiit
• W I.l.lx
(A<Mr.-
l\o\%
^0-VAw<iA\; CjI
MEDICAL CERTIFICATE OF DEATH
DATi". <•]■i>i:Arii
,,„il,i A ip.iy) (Vf.-ir^
I ni:Ri:r.\' Ci: UTIIA. Tliat I ntteii(U-<l dcccast-d fp.in
— — ^I(/) In ~~" I<P
lliat I la^l ^a\v ll ali\c on T<p
aii'l tliat (U-atli occiirrcMl. on tlu- <latv â– ^taU-il altovi-, at
;\I. 'riic C-MSI-; Ol' DI'IA Til was as follows:
jS a_a..<yvva:^ jJ .*^^^ji^o^<^
I jC RATION )'r(i/s
C()NTRil!l"r<»KV
1)1 1-J \TloN
.U,>>///is
fhns
Iloitr
fhiy
( SIGNED )U). fe. "O^^^JUUm
LLvQ 1'; r.,oH (Ad.ln-ss) M\jUAr XU^m
'E^IAL INFORMATION ""'y f^^ llospitdls, Insiitutions, Transients,
SPI . ,
or Re( ent Residents, and persons dyiii:j away from fione.
Former or '\ / ■«
Usual Rpsidcntc^^ l^
O^VUvVv Cj AT Plare of Ocafli ? ^^ Days
Hhpn Has disease contracted,
If not at place of deatli?
ri,Ari-;^(>i- imkiai. or rkmovai.
1-, Ol- m K I
INI
DA ri-: '>; 111 Ki \i • i: i-:movai.
T90S
(Addrtss
(E
Co'XH VjSrv^Kayd
A^^
22
^f
IN. B. Hvery item of inf ,rm,n5on «liouI(l h- c.rcn.lly supplied. AHK h^ ..Id be Htnte.l HXACTLY. PHYSICIANS «hoi.ld
stiitc CAUSf: OF Dr.ATH Jn plnin tcrm«, thnt it miiy be properly claKsiticd. The "Spe^iHl lnlfo.'.nuli .n ' for p«r-
HotiB dylnil^ away from home hIiouKI be ^iven in every iriHtanee.
I
1
m
J 1
I <
I
I
!
ft
I t
tn
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD TPf
, f 1I.:,M!> I- No :^ t -.^rwT^ HK: »' C
REKtH ro l3A<_r\ UP v-cniiriv^(
I 1^ r ^ 1^ t»»^»»»^^'»»^'**'"*
lle<^isfcre(l jYo,
1 1 94
^^/c AVVr''/, iXc\^'LA^ aS" l'-)<>\ *
X<y^A.^ "Ixa;-^! Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
XX. 5. StaiiCiaiO )
PLACE OF DEATH:
County of O^O^^Tyj J AXX/Tv^tAA/CUi City of
N
o ^^0 IJLv^cL^:^ St,; 5^ Dist,;bet. 5v 0 tL and ^ I -U>
r ,F DtATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED TOR UNDER "SPECIAL INFORMATION \
( ,F DEATH OCcJrRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER J
FULL NAME
'>i \
PERSONAL AND STATISTICAL PARTICULARS
CO I.' »K \
(^nJL
vX'ykAX.iJ
â– i- i;iK 111
lo
YvJl
X
\
x-s
>-l\< .1,1",. MARK II 1)
r.ik rni'LArH
(stale or CuimUvi
' ■• ; Ml
1 A Tli l.R
lUR'niri, Acic
o|. i\iin.:K
>» X ! I ) 1-: N N A M 1-:
«)1 Mnrm.R
lllRTlil'I.Ai I".
oi* Morm-.R
' '-' ' ' C'l Hint I A I
'I ' i i \ r K iN
A'
"wxyAJL
., /-./-/. ' ,.. 5l^ 'â– 'â– "> 5l .'A''///' X3 /
',/
III!' \!i. i\i- s r Ml- 1 1 i'l.; RsoNAi. 1" vRinr i.AKS AK1-: TKri; I'l » I'lii-;
Ki,-.! (ii M\;^x n<»\^i,i-;i)<;k and r.i.i.u;!-"
Oiif'i- mint
^.Wxt.
( \(l(lrfss
^ao jJU^a/cLolo:
t
(Ycar^
MEDICAL CERTIFICATE OF DEATH
(M.)iitli> jT 'I)ay
II I'.I'J I":i'.\' C1:R'I"11"N. 'I"li;it r atUnkMl ilcccasfd frniu
C to vAAAXX ^H i*;oH
.CV/V up C to
tli;it I la-;l --.iw li'O > > ' ;tlivL- on
and tliat '1
«^ M. The CArSI- ni" DllATll was as follows:
s.iw li'^ > > ' ali\ L- on UV-A^\-0|L '^v ^''9^
Icatli (ircurrecl, on tin.- ilatc- statL-il above, at CKjyX
1)1 RAT ION
)'('(;/ -.s-
Mouths
l)a\
s
Ilou
rs
DIRA'I'ION )V,7rv .lAv////,s- /'>(jys Hours
(SIGNED) \j. \A. LwYvfetr^V M.D.
0.S ic,oH f A.ldrc'ss) ^l-<Lt <V>\xi JlOlHAKXVt*..
Special information '»n'y f'"^ Hispitdls, Instifutions, Trdnsicnts,
or Recent Residents, and persons dyinj ,iw.iy lro;n home.
Former or
I'sudI Residence
When was disease contracted,
II not at place ol death?
How lonq at
Pl.)(e ot Death
Days
I'LACi: Ol- lU RIAI, OR ki;M<i\Al, I DA'lJlof UfKiAi- or RICMOVAI,
rXDl'.KTAKI'.R
(Addrtss
^. K. 5;vcry item of in? .rmntion should be cnrefully supplied. A(JB sli^uld be stated EXACTLY. PHYSICIANS should
Htute CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for par-
sons dyin^ away from home should be ftiven in ox^ry instance.
-'I
i.ii
' Ii
â– i'l
I, tf'i
I;]
'«o
i
W
RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
! !• iiM i'
z^/ — . i,.v r *■1
REFE.H ru HAUrv wr v^cr>i<riv.>^... .».. ■■•
Uei^L'^tercd -^^^
1195
w
ir^
Itr.^.'Lv^ Deputy Health OfHcer
DEPARTi^ENT OFPUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( "U. 5. 5tanC>arO i
PLACE OF DEATH: — County of QJxX'^ O-'^cx^out^c City ofUAX^ ^^^XX^^^^^^-
O
NoJ
L.d
(y^l^vXOulSt; Dist.;bet.
" and
v. 'O-*^ r >-^ ww<^ „.. AeiiAl aresmrNCE GIVE FACTS CALLED POR UNDER SPECIAL INFORMATION' \
( ' ';r:^.i'iiii::':: ::TJ^'^.\'i o^^nst'itJv^o^n'o.ve ,ts na.,e .nst.ao or stre.t and nu.ber. ;
FULL NAME
Osj^rro
ij CLW^
PEIRSONAL AND STATISTICAL PARTICULARS
^cJL
DA
LL'>On^~v^c^-
â– ^5
K l< 11.1'
MIRTH PT,A('l-:
111' 1. \ I" 1 1 1." I,'
MAIDKN*
( 1' ■■> • ■^■^• !
HIR I iil'LA< \'.
OK MflTHFK
">â– *'!â– r sTii i\'
yronf/ts ^ Pays
/'i (iiicisro
Yrars
in: An<)VKST\Ti:i) I'-'K-^ONAM'ARTICrr.ARS AKHTRrH TO THK
HKST OF MY KXOWI.KDOK AND nEL,IKF
h
ifMniunU UL- 3. LI . "^Jl/VUlA-oJL V>0 &-^V^t>oJL
f Address
tEDICAL CERTIFICATE OF DEATH
M-.titlit i^' Davt V.,M)
I ni':UI{I'A' CI-:RTli*\. ThMt I atU-iuUMl deceased Inmi
ilive lUi VA-(vA.^ A.6 Tt)0 '
iM.l Ih.it .ItMlli oc.-urre.t, ^n the iliitv stati-il above, at O b 0
— ^
\[ Till ; \! ^1{ i)!' I)1''.\'I'II \va< as follows:
-l\V 11
-C^YV
JlKrtXv. Ju>-'Vv<3/<5
k^v-/CL/xAJ
1)1 RAT ION );w;-f
CONTRiniToRV
Month!i
Days
Hour';
DURATION
.]f>^ith^
/\iv
( SIGNED ) UJ . J . JJ <X/\^xxiLA.^'vx/
M.D.
Os'i* iqoH (
Ad<1re>^--)U. "^-U^. <i-g>^ %(v^><p.
SPECIAL Information only tor Hospitals, Institutions, Transients.
or Recent Residents, and persons dying away from home.
Former
Usual ResMence
esMence NJ • GN-
When was disease contracted, (-? M
If not at place of death ? VJ- C?v,
How lon(| at >-v
f»laf e of Death ? M
Davs
PI, ACE OF nilRIAI. OR K1;M()VAI,
DATlCof HiRiAl, or R1:M<)\"AI,
u.^ a
(Address
wrwrmm^-irmmmmmmrjr%
mm
N, B.— -Fivery item o? Informntlon ahould be en
stBte C\USE OF DEATH In plain tern
Rons dytnit flway from home nhould be
ppicd. AGFi HHdilll !»• stated EXACTLY. PHYSICIANS should
may be properly CTa««lflad, The "Special Information" for par-
may be prope
-vary Instance
I
!! .t]
ll
isasm
IT
i .;â–
i
WRITE
PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
_ . . . •■» «- w.rf^»« itti^k -m ^ I I /^ *^ I ^\ tki I
.,-,1 .,1 Ih :.;iii 1
^. r,\ !■'••
REFER TO BAC»S 0»- LitM I IM<-m i t r\->n i ii s? » nw^ i »v^'»
/>^//r I'll ('(I . U^^^OA^VwXijfc ^S"
/V^VH
lle^lstei'cd J\'*o.
it 96
dvw>t)A^Aw.Aw^
Deputy Heakh OfTicer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate ot Beatb
* { XI. S. 5t.1n^av^ )
PLACE OF DEATH: — County of OxXm; JAaxy-rV<^c<iC(; City of ^<Xm; 0 AXXa^x/CAA,<M)
No. IHOl 0 i
L; 0 Dist.; bet.
and
(
Cav.^JLA^^ St,
_„„.. iiciiBi D r =: I nr Nr E" r.i vr facts rAHPD for under special information
«^/wiX^ )
FULL NAME
O^L^Vu
X^Y\a^\Xyv\i
PERSONAL AND STATISTICAL PARTICULARS
xAk ""â– ""IdI^-u
1. > '1 i; iK I'll
\' .I''.
55>
M. !l'll
)
5-
^
\^
(Year*
/),;!>
u iiM >\\i:i) OK DivoKci: t)
Wiit'iii vni-iiil di ^ii'tKit i' 111)
I'.!!-: rn IM, A'"!-:
I state or Ciiutitry
y
!• ATii i;k
p.iKriiiM, \(K
<M ixriii'.K
"^; 'i â– '1 (.'(Hint I \-
MAIDI-.N NAM!'.
<»i- Moiin;R
iMK-rii iM, \ri-;
"1 MOTHlvR
' ^t;i!!- m (.'iiUIltlX^
Oo'>^
a^Xaj oUxa^vx^^^CUIa..
< I'AI'l'Al |()\
h't'sidf'f in Sijti /'K'Uii^r.} lo )'■••!!
Mnitlr
nr\
liii: AHox}.-, sr \ri:!» rt<'K>;( »\ai, rA:<i"u"f i, aks ak j; I'RrK to tii )•:
I'.i'.sr ()i- MY K\()\\i,i:i)(-,i': AM) iii",Mi;r
'Inf.,- maiit
(Vtrifl
MEDICAL CERTIFICATE OF DEATH
Dx'ii', (»!• m: A I'll r\
ULvCL IH
(M.)iitli) /T (I)ay>
I II i:1n i:i'.N' Ci: UTI I-'V, 'I'liat I alteiKlcd deceased from
MtXy^V rooH to LLucO "^^ i<;oH
3 n (T ^u u
thai i la-.1 ^.t\v h A^'Y>^ ah\i-oil VAA-A^CL ^ »■Kp "
and that .U-atli oociirrcil. on tlie date stated above, at O • OU
M M. Tlie CWrSi', ()!â– DI'.ATII was as follows:
XXX/\x«
nr RATION Ov )\'ays MouHn Days
Cr >VTK' MUTOR V dU >OCXA?-<XJLa
Jloiti s
DrKA'l'loN
(SIGNED)
)Vi//'v
Moiit/is
VJV. dv. MVAxytLcrv
XH. i(/>A f .\ddrt-s<)
fhivs
M.D.
Special information '»nly for llospildls, institutions, Transirnts'',
or iierent Residents, and persons (lyin;j dwa> froii home.
Former or \UK<i
Usual Residence I" ^^
When was disease contrarted.
If not at plareof death?
o^xamXI'
Days
I'X All-: oi' luKiAL ok ki:m<>\ai
HA'l"K ')}' HiKiM .'1 RKMnXAl,
<UJXA!t£A/w LXxlAAjtA.^rvv OAA.'we/vXxJo djK^
(A.i.iie^s H'XH JLJ-tA>x^ux<ijLM) at
N. ij. Hverv item of iM?<.rm,.tion shouUI h. cMreV'ully suppllvMl. AHR «^ioul«I be stated RXACTLY. PHYSICIANS should
state CAUSE OF DFATH in plain terms, that it may he properly classified. The "Special Information" ?or per-
son* dyin^ away from home should he g^iven in every instance.
i
,!
I'J'
I I
it,
fl
111
it
»^M
1
:X â– â–
â– I
4,
f
1
»ll
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
,,!,,! IK, .nil I' ^ â– - ^T'^-;r' i'^''^'
REFER TO BACK OF CERTIFICATt HJM I ins i nuo iiui^io
Duh' riled, \\x^<X\^^ %^ ^^'^^^"i
Reciititcred .A7;.
il9?
Ov^tr^LA-^^^ ^
Deputy Hi. * OfHcer
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of IDcatb
I 11. S. 5tanC>avC> )
J? QSTl ;S ^
PLACE OF DEATH: — County ofOcL^ru OXXX^p^ca^^o City of (l)>CL/vu OAXX/>AX^<tX^c>
No. lo^^
and
.^C. St.; 2. Dist.; bet. dJxA^'
r IF DEAT*\ OCCURS AWAY FROM USUAL R E S I D E N C E G ! V E FACTS CALLED FOR uioER "SPECIAL INFORMATION" ^
( Tf DeUh OCCU"*- - I wn<.P,TAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
OJ\J~\\.
IRRED IN A HOSPITAL OR INSTITUTION GIVE I
1-
FULL NAME
XXLy^\)
.1
PERSONAL AND STATISTICAL PARTICULARS
QO| ft I C<„.,,R
si:\
|\11 nl l.lKril
N!..n\li
^tja($.
11.
. I)avi
Cr*VA-
qoH
V I ai )
^i\«.i.i:. MAKk ii:i).
\\ iix iw i-:i) OK r»!vnKri:i>
â– W-if i;i -
luk 111 I'l. xt'i-;
' St:iti' or I'lniiiti \ *
N \ M i 111'
I \T1! IK
lURTlIl'l.MK
OI- I Ni'in-R
'Sl-it. .,t (â– .iiiiili \-'
â– iiat I'lMJ
MEDICAL CERTiriCATE OF DEATH
DATi'; i)i- 1)1".. \rn r\
(M< lilt 111 /T (Day^ (Year)
I H I'ik i;i'.\' C!{RTI1'\', That I attnukMl (Icol-mscmI from
LLu^ 'X'b 190H to LLlAXD. '^^ KiO H
tliat T last saw h alive 011 • T<p
aii'l that (irath i)ccurre«l, on the ilatt- stattMl ahovc, at
M. Tho CM SIv Oh" DhlATlI was as follows:
DC RATION
)'i'tIJ-S
J/, >>//// s
/fays
//o/ns
C0NTRI1U'T()R\' ^<0(nAA>v/QJL \J Kv^^OAA-^-XX-OX
M.\Il)l-:x NAM!-:
<•] Morill-.R
niK |-nri. \ri-;
o|- MOTIII-IK
'St:Mi c.r <"cpiiiitiA-
,01 V) U5-VAA/^.XOwXX.cL
)â– .,/,
M.nlll,
'\'\\V \Hi y\V. SI' \ !'i: I) 1M.:kS(>\ M. 1- MvlI'T 1. AkS AK 1', i'K ll'. I'l > Til V.
i'.i;sr oj- MY K NOW i,i: I )(.}•; and i',i;i<n-'.i'
''!:if" lii.itit
1
I ) r R A T [ O N
^SIGNED
Af.'Nt/lS
00. VlJlLu
fhu
'\
Li-^a XH. looH (A.l.lrc^ss) 0.^0'
d
:CIAL INFORI
t
ft^AVOAct
I Ion IS
M.D.
SPECIAL Information only tnr Hospitals, Institutions, fransients,
or Rp(ent HfsiJfnfs, and persons dyin.i anay frnn Iiotip.
Former or
Usual Resldenrc
When v\as disease ronfrdcted,
H not at plare of death ?
Ho\s long at
Plare of Deatfi ?
Days
I'l.ACi: oi- nruiAi, (iK iovMuxai,
l»Arj; m! I'.ikiai, or KKMOVAI,
LAaax:i 0v5" T90H
Adit.
IN. H. I.very item ot* inf)rmiition Hhoul.l h- ciirot'.illy svippHv-il. A'lK kS. ild be statcil I.X4CTLY. PHYSICIANS Khoiilii
«t«tc CAUSn or DI:ATH in ptjim ttrms. thsit it m:i> h- pff)i>Lrl> classified. The "Special Information" for par-
sons ciyin^ away from home shoiihl he given in every instance.
' TiFwr
I JjwjfiMj
ii,
1
â– . â– (
II
•1 \
'â– ' j
!
<^m<^-
i
•^
I
I ^
Wwmt
WRITE PLAINLY WITH UNFADING INK
THIS IS A PERMANENT RECORD
ii.riiil ;^t" 1!. :i'i!i
,. -ifX^-^'r-^i ii\ i' C,
//>^>H
2ieo'i\sfej'e(l Xo.
1198
No.
DEPARTMENT OF PUBLIC HEALTH=-City and County of San Francisco
Certificate of IDeatb
( 11. %, 5tanc>nv^ )
PLACE OF DEATH: — County of 0Oy>^ 0/u:xy>vc^-4.C.o City ofO/CL^r^' 0 /\^<X/'>a/C\^<m:)
UJoJLdjUL-k v^ , >.-., — .- .. .
r IF DfATH OCCURS AWaI FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER SPECIAL INFORMATION • \
( ,F DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
St.r
"Dist.; bet."
and
FULL NAME
IjJjlA;
m:.\
PERSONAL AND STATISTICAL PARTICULARS
CCI,«>K\ (J
: â– \ I i' I If i;lK 111 ^ (^
1 l:i\l
\' .}•;
HI
)•-•,/;
( Vcai I
Da 1 .
-I\(,l,i;, MAKl.ir.l),
U l!)M\\!-: I> ok DIVi iK*'!-:!)
W: ■• ' -1 -ori;il il • " .t i.m)
itiKiiin. \oi-;
'Sl.'itc or (.'ouiiti V
\Mt' i>!'
lUKTlli'l, ATK
(St./ ' Miinti\-
MAI!»i:\ NAMH
<t|- MdTIIl'.K '
I'.iK'nnM.Ai].:
Of" M<>Tin;R
Jij'^'xnX)
XKrr\jwX
IQO
(Day) (
9o\
Year)
MEDICAL CERTIFICATE OF DEATH
DA ri-; « II' Dl'.ATH /~^
I M l{R l'".l!\' e' I-: RTI I-*\ , '\'\\a\ I atU'JiMf.l lU'ccasc'd from
CXa^oO, ^"^ KpH to LLaaXV 'X\ Dpi
that I last saw li .<l/v^ ali\c- on UsAa^Q '^1 up ^
and that death of<-urreil, on tlic datr stati-d above, at \
LL M. Tin- C-MSl-: Ol" I)I';A'riI w.-is as follows:
DIRATIO.X )'i'ars
CoN'rkilU'TORV
Months
Days 5 Hours
1) r R .\ T I () N
(SIG
)\'ars
NED ) Ij. dU- M/l OJttluV>-
Mi)}tths Hays
/fi)urs
M.D.
Rr^iifrd in Siin /'i iwi i ,'i> 10 ) ' •'
^ Mifth'^
/),n
rm: aiu ivi-: s r A-n., d i-i-k -i i\ \i, c \ki iii ;, \ks ak i-. ikii". k > 'lii i".
Hl'.S'l" Ol' MN- KNDWIJ'.Di . )■■, AND lU; 1, 1 1'. !•
'ImT. ,.,,,.,„,
an D,oH (Ad.irrss)0.a?, Vj6-u>Jl dt
Special information on!v lor llosiiitdls, institutions, Iransicnts,
or Recent Residents, and persons dyin?} dway fro-n home.
Former or
Usual Residence' OciA
When was disease contracted
If not at plafeol deatli?
•\ ij) How lonq at ^ 0
(MXXA>^AXAAhtyUJk' Pldfe of Deatli? ^MhA Buys
I'i n^H
I'i,AC"K <)1' IMKIAI, OR RI':M()V.\I, DAI"K-): i!r kiai. oi R l^MOV.AI,
r.ND
i:rtak),r \JCr\t«A) ^ UOixAilil
'Address HX'i J O-LcLt^ro 0 CxXe. W^-M,
^'V'^mmimm^rt.f 'mmi mt
N. H. !;very item of infirmiition should hj viircfully siipplkil. Adfi s'l-mUl be stnte.l HXACTLY. PHYSICIANS Nhouid
Ktiitc CAUSn OF DLATM in plsiin terms, thnt it m.-iy he pr.>|>crly classified. The "SpecinI Informtition" for pur-
sons tlytn^ away from homo should be ftiven in every instance.
-i
' 1 -;•
' i • ! -'
w
RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
i;,,ai.! 'â– !!â– .I'th I' N''> â–
•■•;. •s-;. .-.;. i;.V 1' I '
REFER TO BACK OF CERTIFICAFL hUH »rN:3i Huv^i (<wn^a
■■■»ijiiiiiiini.»iiiiii» iiiiiiw^— — ^— «i— i».a— — »^ri— — —— — —
'..
M
I />.//./••//,./, CLv<Wt -XS- l!>0^ m-gLsfcred A'-o. 11.99
"cL^vA.^ "1jla>-u Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Gcvtiticate of IDeatb
( "U. S. t^'tan^nvC> )
Jj ' ^ A ^
of ^'CUTu 0 hJXn^ZAA.xu> City of O/O^o^ J A^XXyY\K:>^^^<^^
'\ f (?
^-v^ St.; 9n Dist.;bet. ^^^:»-^K^-<rvv; and ^ ^
/ IF DTATH OCCURS A'VAv rnoM USUAL RESIDENCE GIVE FACTS called/for under 'special information â– N
(, IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS N A M E |jl N ST E A 0 OT STREET AND NUMBER. /
PLACE OF DEATH: — County
No. 1 I'^s^
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
M.MUlit
'p.ivi
aa
/hi
'-INt.l.K. MAKk !)•■.!'
WllXiWKI) OK I)!V< ' 1 M
■'■• ■•■- :••-■■:iatl(.;ii
li!l< riM'I, A'-]-:
' St.itc or I*. iiiiilr\ i
.j^Aj-^rV^uixx
â– > \ ^1 r III'
1 \iiii:r
IlIKTlllM. \('K
"!• 1 \rii i-:r
'untrv
m\i!u;n \ami-;
HI- Mt)Tni:K
'•' .' 1 CMllHtlN-t
; A 1 n >N
A.)
'vx^rvu-'w
MEDICAL CERTIFICATE OF DEATH
DATi-: ()!•■i>i;ath r^
(MontlO A^ (I)avt iVcar)
I 1 1 i;i'i I:P.V CMF-iTll'N', Til. It I atU-iiiK'<l (U'i'L-,isL-(l fr.mi
UUax:i a i(,oH to LLoco X'X u,o H
tli:it I last ^a\v Ii-.«-^v- alivi' on vJ^A.^«^X3. 'X'X Tgo H
aiiil llial (liath ot'currcil, on the 'lat*.- statt-il a1u>\-<.-, at W
LL M. 'I'lic CAISI-; ()!• DliATlI was as follows:
(."i'N'rivM'-l'n >RV
DIR ATH )N-
i SIGNED )
Months 10 /;,/iA- //(;//;-.s-
Iliilir:^
^^
k
Rrsiifni III Siiti /'niih ■- » o '
1/ ./f/i.
Ihi\
Hh> 1 <il MV KNOWIJ.D' .1-. AND lU-.I.Il.l-"
•:i:int
Os.,Aw^-,-<lA.JrvX
\.l.li
/cJkA^crru Q'i
}\\iis Mouths c) /)<n'.v
NL. O. VIjaxA^ pOL M.D.
( (VVi -f n
^^ i<)oH (A.ldn-;^) HloO \] rUnrXQA^LL/vO.
Special INFORT/IATION only fur H.ispitdN, lnstitutions,^Transients,
or Recent Residents, and persons d>inj anav from liome.
Former or
Usual Residence
When was disease ronfracted,
If not at place of death ?
How lonq at
Place of Death ?
Davs
I'l, \r )â– : oi- lUKiA I, < >i< !<i-:mi i\m.
Q%b OJU^
!»A1K..: I!iki\i, (,i KI'.MOVAI.
Llx.A^ X^ T90H
.\i>):k 1 aki:r NKaJLo-a^ C) vJ CrcUc<Xvv.'
(Add; - 3>C)^ \I lWv^X<YH ^*-*^-^
N. R. Kvery ifcm oV inf jr-m^tion shouhl bj carct'ully sujipH.-d. A^Ih s'loilil be stated [.WCTLY. PHYSICIANS Hhoiird
Htntc CAlISr OF DIZATH in phiifi terms, that it m:i.v be properly classified. The ''Special !nf«)riniitii)n" for per-
sons dyinjl away from home Nhould be j^'^e" '" every instance.
>Ti
m
i
'Ul
I
.4
tI
A-l
\
• .1
'I
1 til
y
m
liiikc
i
t
I
I f;
f5^
w
RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I
Ihtfr /'7/r^/.
nu/'i
REFER TO BACK OF CERTIFICATfc FOH t rMa i hul. t iui>i o
1200
Jice^isfri'efl A^o.
CX.<^<A.^^^
Deputy Health Officer
DEPARTMENT OF rUBLIC HE ALTH=City and County of San Francisco
Ccvtiticatc of Bcatb
, 11. 'I\ iIitan^nl•^
PLACE OF DEATH: — County ofCj/CXA^' 0 AXX/>\CUi Cx City of Ooyy\j 3K^^^<^^^<:^^
No Lvlu,^ L^VU-^xtu (5^^ ^ lvda.l St.; Dist.: bet. and " — )
/T / ,r nrATH OCCURiAWY TRoJ USUAL RESIDENCE CVr facts called rOR under special .NEOPMATION \
0 ( .rDE.THOCcijRRVD IN A HOSPITAL OR ,NST,TUT,ON G.VE ITS NAME INSTEAD Or STREET AND NUMBER. J
FULL NAME
«
U XXXiV<X/W\i
Sl-.X
PERSONAL AND STATISTICAL PARTICULARS
uj yixcti
!K III
\\':;!t Ml - )i i.-il ili'>.i !.'n::l '.I til
"â– ; ^ r]-
(Statt
NAMK ni-
"in. \v 1-,
NTHHK
MAllJl.N NAMl-:
in- Mt»THHK
niRTui';. , 1
<»F MOTH Ik
<Slatf or C' limit \
MEDICAL CERTIFICATE OF DEATH
DA : 1. ' i! : 'I '. i i' ; "\
ij
iVcrtr^
1^
â– IViy'
I II !•■. Iv I'. r.\' Ci i;ill\. That I attni'U-il (Urr.ivi-,1 Itoni
that T lavl <:i\v li " " i' x* <>n -~ TqO
ami that ilcath (U-cnrrod, t'li tht' di'i ^taliil alioM-, at
" Tvn ^^- ''^^''" ^'-^' '^''" *^^' ni'iATH was ;!•> follMW^:
DIR ATION )V<?/-.v Montha Pays Hom^
(. ( )NTRnur()RV
i' XI'IMN
/,â–
V^/0^\J|AjLy^'vAL,cV-
•- 1,', - '//-
Tin", MiOVI-: ST \ II-' I) l't"'K>i«)N \1. !'\K ri*M"!. AK
lu-.srni- Mv KNi'Wi.' ' ' \M> ni:i.n:K
K i 1 T< > "I" 1 11"
' Inforniaiit
Lxr'Vcrv^jL^v/i vj
VVv t^-A.
'\.Mt,.^c ^
1)1 I-J \'ri( )\ ) V(?r\ .]/.»;///;\
( SIGNED ' UjVO-Vvjyv J, .
a
Hours
M.D.
IH T<)(^H ^ \.h1n-;v) UrVCPk-vXA^
3ec8al Information ^nw for
iD^y
V '^v
Special information fn'v lor Hospitals, Inslitutrobs, Transirnts,
or Rnenf Rfsidents. and persons d\inq dwav from home.
Formpr or
Isual Reside ncp
When was disease rontrarfed,
If not at plare of deatli ?
HoH long at
Plare of Dcdtl) ?
Davs
PLAll-: or lU KIAI, ok RF.MOVAI. j I>\ll
rNDKRTAKKK JaxLIm ^^ fo O
^.1
^. B. T;very item <.» informit Jon KhoiiM be cnr-eV.iIly Hupplied. X^W. shouM he stated I.WCTLY. PHYSIC! \NS Rhould
state CAUSr OF DI:ATHI In pljiin terms, thsit it m:iy b- properly classified. The "Special Information" for per-
sons dyin^ nway from home should be j^iven in every instance.
I
â– 1
vA
^ 'V-.H
I
' [I
. *<
I
t J
-.-^
A^
'•'^^a^
Tfi
li' I
ni ;
^i*^*ft
WRITE PLAINLY WITH UN
FADING INK — THIS IS A PERMANENT RECORD
,,1 II. .;lt!i IV.
l}(ff(' Fiicil ,
;.V!' t'
cMj-^^aa^
as-
u)(n
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
" 1201
Resist ci'cd Xo.
Deputy Hccfth OPIcf^r
DEPARTMENT OF PUBLIC HEALTH==Ciiy and County of San Francisco
Gcvtificatc of IDcatb
( "U. S. t?tnn^ar^ )
PLACE OF DEATH: — County
J asp \ (^
m
Ng.
St.;
Disl.; bet*
/l/T DEATH or. CURSAWAVFROliL, ., ... r
^ \) IF OEATM OCCURRtD IN A JtOSPlTAL OR INSTITUTION GIVE ITS NAME I
aiiJ
USUAL RESIDENCE GIVE facts called for under special information \
^ nstead of street and number. J
FULL NAME
ijJjLAj
AwAw-CL/U
t) 0 x\aA-
Ct<i-Cnk
^i;x
PERSONAL AND STATISTICAL PARTICULARS
' CnioK
-^!'v\iji
â– ;; K rii
A' .!•:
5^
T ai
WIDnWKn (»K I> •
lUK 1 li I'l, \>M-:
'St;iti' or C'umt I v'
wMi-: oi
1 XI'liJK
I'.iR'nii'i.ArH
"'■• 1 \rm:R
-â– ' â– .nl!\
M \II)l':\ N WIl
OI- MOTHl'.K
lUR THI'l.Ari-.
(U" MOTHHR
"-^t:it- or rnuntrvi
» cri'A ill IN
0 AaaX-'ClaJ" 0 A^/YVsy^^^J^JV^U^y V
IV»EDICAL CERTIFICATE OF DEATH
DATI-. Ol' 1)1. AlH
V\
d
I MoiiHO X iDav^ (Vt/ar)
I II I{K i:i'.\' c; i;R'ril''\', 'rii.it I ntU'iiKtl «Uih-;iso«1 frMm
1 1 /)
to
tli.it I l:ist saw ll -^ alive oil
I()0
I (/I
ami that tirath mccu rrc.l, «>ii llic diU' stati'i] abnvr. at
M. 'riu- CWrSIv Ol" I)l{.\ Til was MS follows:
QP> n ou
1)1 RATION )\'ar%
CONTKUU'roUN'
4 ^J^.^U. i4tG<v^i
-X'.;
^Vv.A-O-VA^'CyA
Moil tin Pays
I Ion IS
\'',:lll'
11!' M'.DVl', SI" \!1I) IM'", !<S< i\ \ 1, )â– XKrUT I. \i;s AKi; rK!!-". i* ) 1" 1 1 1
i:i-;sr ()!• .MS KM >\\i,i:iH-, 1-: anh hi:i,ii
, lilt
^\<Mlr
1)1 l\.\'ri<)N )"''/r\ .7/W/////S- /^/r.s- IliUirs
f SIGNED ) UyVXrvUA; J. MJ.U). X(L^^ M.D.
oLo i()'i H ( \M<1 ii-
SPECIIAL Information '»nlv Inr llnspitdls, Inxtitutions rrdnsicnls,
or Rerenf Residents, and persons dvini aw.iy froii homo.
Former or c. i i) (0 D ' ""^ '""*' '''
L'sudi Residenre I C) I H ^ a% \. ^ \)^^
>AX/x. H^'i.K e ol l)e.ifh ?
. Odvs
When was disease rontrai fed,
If not at plat e of deatfi ?
r!,ArK<»i m'KiAi, ON ki<;m(»v.\i, iiNir,
U/oJkXxx^v^^
!<i:mm\- \i,
U-^-^ ^5 T90H
N. B. F.very Item ..»' i-i? .rm;it ion kIioiiIiI b.- ciircfully siipplictl. \'\\\ shouhl bu Ktiitccl KX \CTLY. PMYSICI AMS Hhoiild
state CAUSr OP nilATII In pbiin terms, tbiit it msiy be properly cluHHil'ieii. The "Specini IiilTormiitlan" for pwr-
Rons clyin^ nway from Iiomo slumlil be J^iven in every instnnce.
â– **!*5*4
Wfm
: (
l^^]
1 1 i
I •
I;
I
â– * 1
!((i
ilia
\ , I'
simnw
un TT
i
â–
\"\
w
I
. ' ,
WRITE PLAINLY WITH UNFADING INK
THIS IS A PERMANENT RECORD TPE
1 • ■i I '
l,:i;ih iv^
1!\ 1' t'
Date Filed , \X^kj<XD^j<^^^aXj 'X^
rJ0\
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
i202
l\e(^ish'i'e(l jYo.
DEPARTMENT OFTUBLIC HEALTH=City and County of San Francisco
Gcvtificatc of Bcatb
( 11. *In *IitnnC>aiC> j
PLACE OF DEATH: — County of ^O-rr-^ OAXX^^-vc.^a<:ity of 0<Xyy>^ J .>v<X/vv^oci'CO
1^
No. lA^tu^^'
A / IF DLATH OCCUR
U \ IF DTATH OCC
<Xh SU
•Dist.; bet.
and
R-alAWflY FROI>* USUAL RESIDENCE GIVE FACTS CALLCD FOR UNDER â– SPECIAL INFORMATION ' \
RED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
<L^ r\ (VULt
K^Ou^'yxA
X^'>^<X''
?)
M nth '
n.'v
'Viarl
\ ' â– ! â– ;
HI
1
lo
:.; . MAR !^ 11.1>.
\\ • ■'.■ill -'.ri:,! i.v;....-.' ■...,!
i: I; llll'I. \i"l-:
! \l II 1 K
I'.IKIIIIM. All.;
<>'â– I'xrin-.R
-' ' • 'omit I \
^t \ii>i:n- nam i:
«w Moini-;K
1'.!!; i iil-KAr}';
'»l MtiTMI'K
! ^hil' '>i OotmH \
(^
0 >L/'>'\XxX^ v<>-
,^<X'»V; (JID/CL'^-V-CUL'^V'
il5i^
.laOOoo^^
ft)
A'>
a.
XJZyW'dL
MEDICAL CERTIFICATE OF DEATH
nAii-; ni- Di; \ I'M
LLlv,^
il):iv) [\\-.n)
Month I A
1 II I'.K I{1'.\' CI'.R'rn'W TIlMt I lltUMl'ltMl .IcHWlSod ffoMl
lli.tt I last ^a\v li -^'^' alive on vA-V-AXX. '«^^ 1<)<1 '^
0 ,JS
aii'l that (k-alli occurred. >ni the date stated almve, at i v;
Lv M. The CM S!' oi" DI'. A Til was as follows:
1)1 RA'IMON )V<//-.s-
C( »\TRird"r<)UV
Monlhs
Days
//tKirs
I ) r R A T 1 () N ) '(Vrv Mojitlis
/)</!
'S
( SiGI
^
' HA'i r \ 1 |( »\
f^uii-'. : II S,u! â– 'I O U
I'll }' \li( iVl', Sj- \:-!l> 1"I-K^( )\ A 1. !• \K ri'I I, \ K-> AR1-: TKfl-: '1'" > T! II-'.
I'.i'.sr (>i MS' K Nowij; !)(■}•; and 1!i:mi:i'
' I n li !â– nri ii I
c.(?.%euju
(A '1(1
r<- UXu^Co. Ob(yA.^vXcJL
an looH
Adil res- i
ve.
1 1 out s
M.D.
SPEoIAL Information '»nly for llispitdls, institutions, Transients,
or Recent Resiilenfs, and persons dvin] .r.vdv fro-n tiome.
Ilsiidl Residence oOSM lUcu^v 'TH
Usual Residence
Wlien was disease contracted,
If not at place of deatli ?
How long at ^
Place of Deafti? O .. Davs
I'l.ACi; ol- lU'KIAI. OR Rt;Mo\ \I. I ' A T 1
LIa^<
. ; i<i;m<i\ \I<
'^^ T 90 H
r XI) K R T A K 1 â– : K OvD . Vl . VJ jlIxa-^uL'v ..
'A<l.li'
IN. n.-
-Hvtry Uem uV i-iVormjitlon Hh,.ul<l I..- ^Mt-cViilf.v suppliea. Af^F. «S.»vil(l be Htnted F.X4CTLY. PHYSICIANS should
Htiitc CMJSfZ OF= DIZATH in plnin terms, thiit it miiy l>e pnjperly classified. The "Si)ccinl InV'ormntion" for per-
son* dyin^ nwny from hfntic Hhould be ftiven in every inBtnnce.
'«
/ r
, I
i l:
h
; f "A
â– â– \\
I
li
^!f
'lit. I
• I'
II'
I
1
1
1
i
1
WRITE
PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I It. :,-y\- 1 "N.
, ^■••^:X:- i;\l' r
l)f(h' Filed , \Xk.\.XX^JoOZ. QwS"
Deputy Her!**! Offin^r
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
1303
Bc^ii.sh'rrd -jVa.
DEPARTMENT OF VUBLIC HEALTH-City and County of San Francisco
Certificate of IDeatb
PLACE OF DEATH: — County of C:W'CA.<X'V>xX^rA."to Gty of C3 0.<l/vx:^^^>^X/T^±x>
No.
(
V
C^ix^Xcx,!)
St.:
-Dist.; bet.
and
,. o^TH OCCURS Uw^v TRO. USUAL R E S â– D E N C E o > v_r _ r.CTS c--,^;- ^^^J ;,%%-'.%^'rr^^^^
irlbcATH OCCURRLD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME
FULL NAME
-i.\
PERSONAL AND STATISTICAL PARTICULARS
L
1 \ ! i , 1 'I
\' .I-;
Kill
r%^^.
W' •1\'\
( V<-;ir)
a?
1/ •'■/.'
M AK I 1) ! t
WIDoWKI) OK
I'.ik iuiM, \r)-;
' St:it( or c'Dimtrv^
Oo'
<1
(^
Cj /Ol/>^ 0 X.Ol/-a.<:a^<:ix.-
NAMl (M
I \'rii i.K
i!iK III I'l, \ri-:
MAII)i: \ NAM J".
<)1- MollH'.K
iilRI 11|M.A> l'.
'>1- MO'IIM'.K
'' I' 1',^ il( »N
/;
yCC'^^xJUi
\
s
vJa/yv>-W
aX/-oJ(j
OAX
<KX,
X^^^y\/XJ<X'
1
S,iii I I
/â– ,;
1 III' \iso\-i-; ST \i-ii) I'l' !<s. )\ \i, i' \K 111!! \KS Aki; I'Kr I-: 'I'o I'lii',
lU'.-iT ()|- \\\ 1>L.N< )\\ l,i; DC. !•; AM) lU'.MI.I-
' I:ir .•iM.illl
IV»EDICAL CERTIFICATE OF DEATH
PA'1'1'. « »1 ! )! \ Til r\
UaaXV ^i r9o\
(Montli)^ 'I)riv) (Yf.'ir^
I Ili'.RI-.l'.V C i:RTII'\', 'Pliiil I atUiuk-.l <kH\asc<l from
tn • I(p
_ — j^p
I(;0
- \\\\\V <M1
tlial I l.r-1 sa\s h
ami that tk-ath ( iCfurrfd, oii tlu' <lalr â– 'Atak'il above, at
M Tlir C \rSI': (>!â– I)i: ATll wa-. as follows
J ^A^'jAJk-X^-A^cL
1)1 RAT ION YtaiR
C()N'l"Kir.l'i"()I<V
DTK AT [ON
Mo II I /is
/hiv
//(>in s
SIGNE
i)N ^''"i^
M.'iilhi
/hiv
u
-«
//I'urs
M.D.
\,l,!,-,.<,s) O/CLt.VO^AAX^yvU V-<V
Lm^v.c\^ 'XH i()o*A
SPEci'lAL iNrORMATION "nly ior Hospif,ils, Institutions Transients,
or Recent Residents, .ind pprsons dyinq .iw.iy froii tiome.
Former or
Usurti Residence
Wlien was disease contracted,
If not at plai e ot deatfi ?
How loni) at
PIdcf of Deatfi ?
Davs
ACl". <tl- lU'RIAl, t)k ki;m(»\ai,
I M)];R TAKI-.K V- VJ . \J
1) \'\'l^'>\ 111 itiAi. or K1-:M( iN \I,
3^b TQOH
^
N. H. viverv item ..f inVo.mi.t Jon shonl.l b. cur«t\.n> s..p,>l1.-.cl. ACIP. h'i,....M be Htnte.l HXACTLY. PHYSICIANS «brn.l.|
Htiitc GAlISi: Ol- I)I:ATII \» plnln terms, thnt it m:iy be properly cIiiHHilficd. The "Spcciul Iniormntion" for p«r-
Kon* <]yin(;t nwiiy from home shfuilil be ftiven in every iiistJince.
I
I
u
t;
i«*f*.
-w^
r^i'
I
\ i
i 1
I i
1*
â– I
I
WRIT
E PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
|. M'l 1 \-'
'.•"-I'^II&IM'd
X(y^.^>^ ifi.^;^ Deputy Health Officer
REFER TO DACK OF CERTIFICATE FOR INSTRUCTIONS
J 204
lioilisfi'ird 'jYo.
DEPARTMENT OF PUBLIC nEALTH=City and County of San Francisco
PLACE OF DEATH: — County
0
Certificate of E)catb
SI % , A ^
ofCj-a-v^ 0 A./O.^'CvAAMj City of 0.<X'vv J X<x/>A^^<.xi^«
N
cOfc.
St.;
Dist.; bet.
— and
/ .r DEATH OCCURS avLav fpow USUAL RESIDENCE dVE tacts called roR UNDER -SPrCAL '^^°";;f*J'°~" )
( ,r DEATH OCCURRED IN A HOSPITAL OR .NST.TUTION GIVE .TS NAME INSTEAD OT STREET AND NUMBER. J
FULL NAME
- r \
PERSONAL AND STATISTICAL PARTICULARS
r< »l,t iK \ (\
'.iK 1 II \ (^
IvvOiVv-
?)1
M..tHh' I>:'V
M.iiHi^
r. MARKli: !•
w i:i) OR nivoKcM-:?)
^
}
I ATii i:r
lUK 1 li IM, \ci-;
'â– <Miiitrv'
M\ini:N NAMi:
OI' MOIHHR
!UKl-!iri. ATI'
OK MorHHK
fmrtt"' '>y C..', 1.1.1 1
A'-
\J-^-\>
H
M
/'.â–
ui->r(ii. .>i\ KN'i )W 1,1 .i )(■,]•: and ni'.i.M.i-
(ii
)f â– ni.nit Ot). X^cOkjU J\9 CHL^X*wi--oJb
A.I,':
MEDICAL CERTIFICATE OF DEATH
i).\ Ti: ' 'I I'l.A I II
a
3LI
NT..!itli> A 'n.iv
I Ili':Ri;r.\' fllRTIl'N', IMml 1 attLMi'Kil .U-cca^c.l hnm
CLo^ 15 T90H tn LLawVQ 'X\ T.pM
that I lavt s:ixv li A, ,> . alive on L\A.V^ '"X I i,p 'h
;md that iK-alh ocourrdl. on the <latr <talOil ahnvc, at 3
VJ >[. 'Ihr CAlSlv Ol' DI'ATil wa-^ as follows:
rrOZ-'LA,/^'^ v.'^y^WA.^Os.
1)1" RAT ION )\ars
CnNTRIIU TORN'
Moil tin l^ /^/iv Hours
DTRATION
) V,/;".v
}[o)itlis n^ys
(Signed^ hj vl. vaa^v-tuq
PE<^IAL Information onlv for Hospitdls, institutions, Trdnsients.
//ours
M.D.
SP . ,
or Recent ResiJents, and persons dyinq anay fron nome.
Former or
IsudI Residence
â– WvOk
/W^O^v^N.*-^ X
Whm was disease rontratted, H
If nnf hI niare of death ? LLvA.O,
iiiKiAi, OR ki:m<>v.\i.
HftH lonq at
Place of Deatfi ?
t: .. Days
•ri.ACi-: t>i' r.
^ Oiv.^
rNi)i-:RTAKi;R
V . '. . ; •
i).\ii'. o; !:â– iM \i. (11 ri-:movai.
305"
N. B.— F.verv Item of information hHouIcI h. cnrofully suppH-d. ACE should be stnted RWCTLY. PHYSICI ArSS «houId
state CAUSE OF DEATH in plain terms, that it may be properly classified. The * Special fntormation ^or per-
sons dyin^ away from home should be ^iven in every instance.
1
'' "a
'i
\lA
m
n » t .
X
n TW
"•
vi
\
1 '1
I
« »
!f
m
I \
I
I
f
M
^.
i
-•^
write: plainly with unfading ink — THIS IS A PERMANENT RECORD
}{.Kir<l <,f Ihaltli I- No. :> t-f^T^; ]{& I' C<.
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
KJO'i
Re^li^tered JVo.
Deputy Health Officer
Dafr Filed ,
DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco
Certificate of Bcatb
( "U. S. StanDarC^ )
of C'/CL/Vu 0 Axxaxx^ocl C.C City ofO/CV/^v^ OAXXy>X/a\.AyC^
PLACE OF DEATH: — County
'>k).
f IF DEATH OCCURS AvAv mOW ufe U A L R E S | D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' \
V IF DEATH OCCURR^p IN A HOf^PITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
Dist.; bet.-
and
FULL NAME
si-;x
n wv. I >i I'.iki'ii
PERSONAL AND STATISTICAL PARTICULARS
j COI^OR
VOL'
M..111I1
\''. !•:
OUrt \
\ y.ai.
;l\-i
.1 A. ;////•
I '/■•lit
/>,n
MEDICAL CERTIFICATE OF DEATH
I)
ATI-; Ol' Dl'AIII r\
(Year)
^1\< I.I- M.XKRI}';!).
wiix »\\i:i) Ok i>i\nk(i.:n
'Wiitt in >.(<ria1 <!rsi<.'-nat ion
lilK ri!!'l,.\0|-.
(State or Cotmtrv
NAM)- <)I'
ia'i-!ii:r
lilR rilll, \r|-;
oi- i-Ariii'iR
MMIi|-;N NAM}'
01-' MOTHI.R
i'.iR'rnp[,ACE
<H- AIOTHKR
'Siatf or Coinitrv)
(Moiitli)
I m:Rl-;i;V C1:rTII-V, Thai I atU'n.k.l .k-rr.isol from
^ I9O to — K^o
lliat I last ,sa\v li " alive on
l(p
ami that death oeiurrod, on (he date- stated ahow, at -
T M. The CAl SI- Ol- I)i;\TII was as follows:
IMR.\ri()\ Yrars
CONTRIIU ^()RV
.lA^;////.?
Da )'.s-
IIou
rs
m RAT I ON
)'('(ir.s
(^ (J^
Vo/z/Z/s
/^ars-
( SIGNED ) UV<o^M; J. \h. U). lxLcLAA..<JL
lloii} s
M.D.
<:.i
Special Information "niv for Hospitdis, insiitutVoiis. irdnsicnis
or Recent Residents, and persons d>in!| .nv.tv frnni fiome.
1 .' ,.'/,
i.i'.si f>i- ^I^ KNOW 1,1. i)(,K AND Bi:iji:i-
Former or
Usual Residence
Wlien was disease rontracfed,
if not at place of death ?
How lonq af
PUe of Deatfi?
Days
ri.Ari-: (»)• lUR 1 \i. di-' k i:m( )\ai.
nnfiTiuaiit
-V^LX
V'lihfss
i/ixJC^
IaA-vQ Qvb 190H
i__.^^
NI.l-.RTAKHR JuXL-^ N^^ 0\D .O^Cy-O.-^ V
(A.Ulress 'h\o\X ^ 1 *\ JtL 'hx
' ^mmmmrwnm^
nte CXi?sr or nTlT^^^ ^.-c.ul|> sur>pned. AGG HhouIJ he Htntcl F.XACTLY. PHYSICIANS sh
in, ,1 -1 "^ f^^^l" '" '''""' *-'-'-• »•'"» 5t may he properly .I„HsJtled. The ••Special Information" ?or
ons <Iy,na awny from homo should he ftiven in every instance. formation »or
Oil Id
p«r-
t,
;' M
I 'I
â–º \ r
i •
'1
^ 1
f ;
f rl
iL. i.''.
vn
^'tx^
w
'*ip'
;, .
if
â– >*-^
WRITE PLAINLY WITH UNFADING INK
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
DEPARTMENT OF
as:.
7!)0'\
Ma^istcrcd J\"().
J206
Deputy ^ Uh O ' r
BLIC HEALTIi=City and County of San Francisco
Cevtificate of IDcatb
! 11. S. StanOav^ )
^ Q^ J?
^
PLACE OF DEATH .- — County
ofvJ/CL/^v 0 AxXa^^c/Ca^Cc City of C)/Ol/Vvj 0 ^O./w^^t^^-co
St.; 6'.
lU5yv and
No. C)C)"\ ^\JUOJ\j^'-\^<A St.; 0^; Dist,;bet. -
(IF DFATH OCCURg^AyWAY FROM USUAL R E S I D E N C E G I V C FACTS CALLED FOR UNDER "SPECAlAL INFORMATION ' ' \
IF DEATH OCCU.lRRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREE^ AND N U W B E RL J
^ )
FULL NAME
^i;\
DAII
At .!â– ;
PERSONAL AND STATISTICAL PARTICULARS
i.( >I.( iR
I Kill
\Xwk/-v
Q\jQU^.^.yoA
V
MEDICAL CERTIFICATE OF DEATH
I'ATi-: oi- i)i:\rii
(Day) (VL-ar)
Lm^i
Month)
Tl
M. ■>/>//•
1 : :iri
/),M V
^iN« i.i-'. MARK n:n
will" >\\i:!) ( »K iii\ ( >kri; I)
HI R I" 111' I. \ii
I State I iv y'' -tint I \'
AxLctV-lMAj
NAM I'. (M
FATIll.R
lUK rn iM.Ari';
'>! I AIMIICR
(State oi Coiinti \ I
M \ i Di; N NAM i;
t)i Morm'.R
lURriMM.ACl':
*)i- M<»rm:R
(Slate <.i roiinli \
MontlO (T
I I1I-;KI-;I',V C1;rT11'V, 'riiat I attemUMl (Icccaso.l fn. iii
I (/ ) ti >
tliat I last s.iw li â– " alivt.' on ~
r(>o
1 90
and that flrath <)rciirrc<l, on tlie i\niv stated al)ov(.>, at
"— - M. '\'hr CWrSl-: Oi" Dl'lATH was as follows:
LL Crv^^w,^ CrV >} A\J\..<yi>\ Q
VAV
< »i rr I'A ill )N
/\'l''l(fl',f : I! Si! II /'litlhi'i-'
I )r RATION }'rars
CONTkllU'TORV
Months
yOA-A.'CAxcLx.
Pax a
//.
ours
1)1 RATION Years Moulhs
( SIGNED )U*UnvilA/ J If: '*^
^
Yr,:
M.nilh--
r>,â– ^
III I-. AIlDVl', ST \Ti:i) I'KRsoXAl, I' A R T IC f I. A R S ARI' TRil- li t llif
ni'.ST ()|- MV KNoWMvDr-.l.; AND lU'.Mia-
Days
l'^> KjoH f A.l.lr
Special informatio
or Recent Residents, dnd persons d)in!| dHfiy from tiome.
N onl\ tor ll(ivit.ils, InslitiitMrt's,
Hours
M.D.
Cju
Former or
Usual Residence
Wlien N\(js disease rontracfed,
If not at place of deatti ?
MoH lonii at
Place ol Death ?
, Iransients,
Days
%
v.l.lievs \%^'~\ ViD A^^CkCmIa-attx
A
I'LACl-: Ol- lURIAI, Ok R1-:Mo\\|.
N I J !•; R •]• A K l', R JxjUULm ^K ()v) 'OUX'
" Vll^' I, VI , : R1-;M()VAI.
vXAw\yO, "Xk) T90H
0.^>V'
IN. K. livery item oi? inV'ormiition shoiiM be cnrut'ully supplieil. AGB Hhr>iil(l be stilted EXACTLY. PJIYSICIAINS should
state CAUSi: OF DEiATH in plain ttrrms, thjit it msiy he properly classified. The "Special InVormation" for pur-
son* dyinji away from homo should be ftiven in every instance.
i.ai
I <t
'1
iijii
't'^
? if
• i
m
:• ' *
oP
iii^-'m
^^'
'
i
I
i
H
«
:■«
I
\A/
RITF PI AINI Y WITH UNFADING INK — THIS IS A PERMANENT RECORD
r.orinl i,r 11. ;i!lli !■No '" *":'»'..:'->■HcS: 1' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/)((/r Filed , KXj^^^^Qiyu:^^ OvS'
1U0\
Ilrgislefed JS'^n.
J 207
i_
Depwi
DEPARTiyiENT OF PUBLIC HEALTH -City and County of San Francisco
Certificate ot Beath
( 11. 5. i5tan^ar^ )
Jl ^
JJ On
PLACE OF DEATH: — County oiO<Xyy-\> J A/0./Tr^CA.A^x<;ity of C)'<X'Vi^ J Axv^>-v_^vc<i,c>o
No.aiH
*Wv.
St; ^ Dist.;l5st nrviuuv,
U(>\AXl\;UAH!a
M-
(ir DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E TACTS CALLED FOR UNDER "SPECIAL INFORMATION ' ' \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
'CX^A.|
PERSONAL AND STATISTICAL PARTICULARS
ii.\ ; i: 111
.\(,i-;
III
Ji/C
M..lUll I
b^
%
SIM, I, I" MARK I!.;i),
UIlx )\\ J'l) ni< !)!\(>KtKI)
iWiiti ill s((ciri! ili >is.:nalii)ii)
liiuriir: \'i'.
( St;itc nr (.'nil lit I \'
NX Ml-: <»]•
i".\'nii-;R
r.iki'iii'i.Ar]-:
"! i-\rin:R
S? If' or Tmii iiir\
M \ IDi: N NAM i:
<»i Nil I'll! i;i^
lUKTIiri, \C]'.
Ol- MOTIIKR
(Stat', or Ciainti vl
â– â– -%
OCCUPATIO
MEDICAL CERTIFICATE OF DEATH
DATi-; Ol- i'i:\ III
' Dav^
a
Monllii ^
I ii!:ki;i>.v ci:r"iiI'\-, ru.a r .tiuMi.icd .icccascd I'mm
(\\-ar»
II 190 H
Ili;it I In^l ^aw li »^. ^J ali\c on
a 11 1
U M. tik- cai SI-; ()!• i)i;.\rn
LU>^ ^^ T90H
1 lliat tlcath (jccurreil, nn the date staled above, al C> lo
was a< follows :
1)1 RATION I )Vr/;-s io Mouths Days Hours
ru^rvAA^ .
1)1 RAT ION
( Signed )
Hays
IIou
IS
M.D.
SPECIAL INFORIVJATIOIM ""'y for Hosintdls. ln'^fitu!ioll^, fninsients,
or Reccnl Residents, dnd persons dvinj ,iH,iy fron home.
SLO )>,/.'>
.\r,,>,!/i.
/.',
TH1-; AHOVK STA'n: I) I'KRSONAI, P \ RTK" |- !, \RS ARl! V\< \]'. To Til !
Hi-;s'r ()]•• Mv Kxowi.i: DC, H and iucmi;}'
(Inf.r ni:iTit
(k)ji >^^^v>u, ^
\.Mr.
xw
Former or
L'sual Residence
When was disease confriirfed,
If not .it plare of death ?
How long at
Place of Death ?
.. Davs
AdcHLu
T90M
rUACK Ol" IHRIAI, OR Ri;Mo\AI. DXli:-.' I'.^iOM. (1 ki:mo\\i,
i)i:rtaki:k YCLa^wjuNII ^juw/wj "^m^ L<>
INI)
N. B. Kvery item of iii?.irm«tion should h.- ciiroV'ully supplied. AfiR sS^ild be stnted FiXAGTLY. PJIY,SICIANS Hhoiild
stote CAUSE OF DEATH in plain terms, tli:it it msiy be pr<»perly classified. The "Special Information" for p^r-
sins dyini away from home should be feiven in every instance.
'J ,
i
,1
""I
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' • »
.i^\
" I
[ItU
"B^m^
'i
1,1
m'-
; I
-*^.
WRITF PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
r,..:ii'l ..f H. .'lith !•' N'- •=; t--; '2-:. .•-.- !i.S:I-('.i
REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
â– auvasHHi aH
/)(f/(' /'V/rr/. IXuMX/U-ATfc ^S'
ifjo'i
Jirs^isfe/'Cfl A^o.
1208
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccttificate of IDcatb
( 11, S. i5tnn^aii> )
PLACE OF DEATH: — County ofO/O^-r^ i/xJL/CLt
J?
' No. al 1 ?) X
City of 0<X>^v^ dJj^JUQ.i
St.;
(I F DEATH OCCURS
IF DEATH OCCU
"Dist.; bet.
and
s AWAv FROM USUAL RES I DE NCE GIVE facts called for under "special information
RPED in a hospital OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER.
)
FULL NAME
Vt/\'
KJ^^^rW)
PERl;ONAL AND STATISTICAL PARTICULARS
si;.\ A A (.(ii.dK
i»A 1 1-. I )!■• r.iK rii
A< . !â– ;
M..ntl\)
5S
(I):iv)
.1 A •>////.
i 'i< ari
/>..' 1
MEDICAL CERTIFICATE OF DEATH
DA'I'I-; OI- Dl.Alll ,0
'M')nlli) fT (Day) (Year)
I HI{Ul{r.V Ci:irril'\", TIi.H I atu-n.k-.l deceased fr.-iii
SI\t , I.1-. MAK \s II :•
uiDowKi) (>K in\(iKri-: r)
I, W'ritf in socia! (U'^i^'tialion )
lUK Tnri. \rt-:
(Statf or C'liint! yi
Xn-X^YV^^O^
kJa
XAMi: ol-
i-atiii:r
niRTHi'i, \ri-;
oi- i-atiii:k
' St.'itc or roiiiitry I
MAIDr.N NAMI-;
»>i .M()rui-:K
I 90 to
tliat I la^l saw h ■" — alive on '
and that (U-atli occurred, on tlie date stated alxive, at
-ZT" M. Tlie CAISI' ()I^-J)1â– .Aâ– Iâ– |I \Nas as follows:
up
190
or RATION )V,;/.v
CONTklldTORV
Months
Days
I lours
DI'R ATION
(Signed )
.^fi>)it/i<
/>,/!â–
//,
lUkTmM,ACK
<>i' ^!()TIn•:K
fStatt' or Cotiiitr\
)\ars
Ux^q .X"j i()oH (Addris<) 0/avu dj
IGIAL IN
oJ.'
SPE<tlAL INFORMATION "nly for llo^pitdls. InslilutMns, frdnsicnfs,
or Rerent Residents, and persons dyinij awdv from fiome.
rtii-: \H')VK ST \ ri:i) im':k^(>\-ai, r\Kricri.\Ks AKi- rkij-" t<> tin--
lU'.sT (>]• MV KNmWI.IDCK ANP IU", 1,1 J", I-'
(InfoMiiant
<^>*JCu .Ajeyv^A^/CrvKxX' i\jL>v.^^^x^
(\.M!r
Former or
Usual Residence
When was disease rontrarted,
If not at place of death ?
HoH lonq at
Place of Death ?
.. Days
ri.ACK OV HrUIAI. OR ri;miivai.
k^mz
I'AT);..; lii KiAi. (.1 K}-,M<)\"AI,
IQOS
I .\I)i;rtaki;r J >V\X,^c^^<r^ ' ^aJL>ovU^
'**'• ^' livery item of information sliould be cnrefully supplied. AGR should be Htnted fiXACTLY. PHYSICIANS should
state CAUSE OF DFATH in plain terms, that it may be properly classified. The "Special Informjition" for per-
sons dyinji nway from home should be ^iven in every instance.
. *
i
m
I 1 'â–
m
I
ill
1 ;
■» I
t
II
!l:
I
'^%
' '11
t
â–
m
VMprfMH
f*^
â– % k r^ .1
•^ ^m^^
IIN
il
m
I
"1
m
fiiji
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I)(ff/' /)'/('(/, LLcvciaaaX 'SvS'
I!J() H
Be^isfei'cd J\'*o.
i209
/xH., Deputy Health Officer
DEPARTMENT OFTilBLIC HEALTH=City and County of San Francisco
Certificate of iDcatb
\ 11. 'Z\ i5taiic>ai^ j
JP ^im J?
On
PLACE OF DEATH: — County
A m J( von
nty ofO'CL'^^v ^J Tv^XAA/t^A^ c.<:City of Cj/Cl/TV nJ JV<Xy>Xya'VA./c><j
Oil
'J'
No. I'iK '^oJi\> St.; S Dist.; bet. U /CLAo^ M UJUi/ and 0 A/Oy-yxKlvw.)
(IF DEATH OCCURS AWAY FROW USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' N
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
((0 %
vj
PERSONAL AND STATISTICAL PARTICULARS
II
HAII-" (il IMk'ni
\' .)â– ;
^
JJ
\%
t
I IbH
M..!llll
Oj-^^JLK)
MEDICAL CERTIFICATE OF DEATH
j)A Ti-: ( 'I ni: vvw
'I);tv) iV..;ir)
HO
) â– -â– ,,'/
L
^iN<". 1,1*,, MAKKIl'IV
W(l)i )\VI-:i) OK !i;\( i!.Ml-I>
' W ! i t ' i n V , :
itiurnri, \cv.
\ \ M I (1!
1 \ 1 I! IK
lUUfllPl. \v\:
ni- i\iiii-:k
iStritf or CoimtrN
MAM'!- â– \M 1
' iI Ml 1 1 HI i;
i!iR I'll ri.Ai')'".
IStat. .1 'â– - iiii!'
Cj/Cla>j J.\XLAx/eA^^a^
Off 1^1
^ 1 Ili:Ui:i'.\ (. i;i< ril"\'. That I attc-HiK-.l .If.rasr.l f,,,m
thai I last ^a\v h A.- » . . ali\ii>ii vA-Va^^^ 'X'^x l()0 H
and tliat ilratli n(aui rr<,-«l, on tin- d.iir statL-<l ;i1hiw, al 'X C!A> ?.•
U M. '\'hv CWI SI'! (•!•■i)i; All! was a- follows:
y-\^C. CL\^^
/>.nv
I lour.
1)1" In A'lK >N ^''M^ Months /'iivs iiours
QT^
' >>â– *â– 11' XT It )N
OxJk
/V/OUA/V'C^
H 0 r, ,// VD 1/ „//,,. O
I )r RATION );v;.v ^ JA';////\ /),/|.v IfoiirK
I Signed ^ ^isXcAj-v^ u. \i i Lrv<^c^ M.D.
Special Information "nU lor Hospitals, institutions, Irdnsients,
or RcienI Residents. dOfJ persons dyin) dv* i\ lro;!i tiomr.
Ill' \!{i)\J-, S r \1 I'D fKU SON A I, I'AR ThTI. \RS \R
in: ST oi MN KN<>\vi,i;iJc. H .>0Ln hJ'.i.ii;!"
!•: i"Ki i: 1' t I'll )â– â–
lufu- •-•ml
MN KN<>\VI,i;iJ(.H .>OLI
U<1.1n-
X'yix
0^-i
t
N. B.-
Former or
INurt! Residcnre
Wlirn was disf,isp (ontr.i( ted,
It not at plare of death ?
HoH lonq at
PIa( e ot Deatfi ?
Davs
UJ.ACJ: OI- IMUIAl OR R1:Mo\'AI, "^A' â– ' i'li'M- 1,M..\\;
-livepy itom of informiit ion «houlil h.- ciiroV'ully Hupplioil. AfJK hIiouIiI be Httiteil I.XACTI.Y. PJIYSICI ANS shoulil
state CAUSr or DfZATH in pliiin terms, that it mjiy hv.- properly cI«Hf»ilfictl. The "SpcciHl Informtition" tfor p«r-
Rons (IjinJi nwny from homu shouM be (iiven in every instnnce.
1 ■•â–
â– v.;
'^i\
; f
I
i9<«^«l^
w
:i f
I ;
ii
II
I «
11
--S!!.
Ji
I
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I!.,:,r<l of" Jh :iU!i- I- No. !^ •!!"■-• «r.^~; lUti' C')
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
WKimrsarmmmi^BmimM
â– ajMV SB
/>^/
/r Filed , LLlaXX/l^-^X
as^
7.9^; S
Jlc^islcicd Xo,
1210
I
<:7Vw<J-A^A.A^ ctOL
Deputy Heslth OfHc^r
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Gcvtificatc of £)catb
( 11. 5?. '3tnn^arC> j
PLACE OF DEATH:
County ofO/OLA^ OX^CX^v^v^t^^cc City of Q'^^^-'^^ 0 . V/OyvV/avCL/tMi
I
a^v^<l-i. St/,
(It- DtATH OCr. uJps AWAY FROM USUAL RESIDENCE GIVE
IF DEATH odcuRRED IN A HOSPITAL OR INSTITUTION GIV
Dist.; bet.
and
â– )
FULL NAME
FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
fE ITS NAME INSTEAD OF STREET AND NUMBER. /
KX ^>
PERSONAL AND STATISTICAL PARTICULARS
^M
I).\ :
A<;i-:
III K Til
cJuL
*,'< II, < »K
jJk^ijl.
%x^
W !ilh'
'»i:iM
MEDICAL CERTIFICATE OF DEATH
1) \ ii'! oi" Di: \i II
(I):iv^
'War)
^^
<iNc. i.i* M\Rkii:n
WI In I'A I- ! 1 ( il,' I I '\'
' W 1 ■. •
I'.iuriit'!. \«'i".
fatih;k
lUR Til I'l. \('K
OI' I'A II IKK
(State or Coiuiti
M \i DI'.N N \ M
"1 MuTIIIlK
I51R rin-i.Ai'H
<>!■■%;"•;■11 1-:U
J IIi:Ri;r.V (. i: KTI1"\', That I atUMuU-.! .k-rc-ast-.l fn. iii
llial I last saw h ^V alivf on \Xk^^^ 'XX \(f) \
;inil tliat lUatli occu rrcil. on tlu' dale stalnl aliovr, at O- 10
vJ ->i. Tiu' CMS!-; ()!• i)i-;.\'rii „... ,
foil
as as loilows
(ONTRIIlC'roRV
Months \ /}ays
//ours
6J .^><X/i^^iy-v'\--'^yoJiAZX>\^'
DIRATION
)\'.ir
SIG
NED) U). V). V^O-^^vL
UiUit/is
/)./r
SPECIAL INFC
M.D.
a,^-^-v^L,C
FORIVIATION '>n!y for Hospifdis, Insfilutions, Transients,
or \\nn\\ [Jesidenls, and persons dying dway fron home.
AV ^.'.A-/ /» V/</ /
'\'\\ V. \HOVI-: STATI', I) I'l'-Rsox \], ]• \K ibtl, \Ks \K i: IK ! I! r< ) lH !■;
Ju.sT ()i- MVK v(»\vm:ih,i-: AM) !'.!;i,n:i-'
f\'M
r< ^s
vAJL^\w<l4
^^'tK. A.><L<^
former or
I'sual Residence
LwvvvOl
HoH lonq at
V^6^vA.«- pij, f of Deatfi ?
Davs
Wtien Has disease ronfrarted,
II not at plar e of deatli ?
i'l. AC)-, oi- inR i.\i, ( Ik !•: r.\i< .\ \ I, I i>\!i
Of>uOJLv^
LAaaXD
1 ni»i-:ktaki;r
Ki.Ai. or R i;M()\ \ I,
^5 TQOH
^- '^^ F.very Item of informntion uhoulil b.- ciire^'ully Huppliecl. \^\\, s'lrmld be stilted EXACTLY. PMYxSlCIANS Hhoiild
statL- CAIISI: OF DIIATH in pljiin terms, that it mjiy he properly claHNificd. The '\Special Inforinntion" for pur-
son* d>inji nwtiy from homo should be (iiven in every instnnce.
ti
' 1; ,
X
* »
5 .
ll
'III
■«*^''<m
I
M
I f
I
"^i^-
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
);< '-ii '1 â– â– : i
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
HJO'i
llci^islci'cd ^jYo.
1211
Dif/c Fili'il , LLcvCiA^^c^ijt ^nS"
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
OfTictr
Certificate of IDeatb
I 11. 'I\ ^4nn^ar^ ;
%
(3^
No. 3.
PLACE OF DEATH: — County ofO/CU>^ 0 >u:u-»XjjOUL.C^City of 0/CV>^ 0 AX^./^'V^a^ t>^
'V\) LcjVAAJj S^.; T Dist.tbet. dvXX,x:^/^^^^xx». and ^fc^O^^cAv,
,V^^-C>u
<X/V^t\A>
(IF DEATH OCCURS AWAV PROM USUAL R E S I D E N C E G I V E FACT5 CALLED FOR U N Of R "SPFCIAL INFORMATION' \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
\ ' . 1 .
I'll
M.iiitln (T
2> , ., S
MEDICAL CERTIFICATE OF DEATH
Soi
0^-^
^ixf.i.i-:. M.\KHii-:n.
W'l I>< iWi' I ' 111-' I > :\'i .1.' 1 ■'■r »
lUi-
L
'St,-it> Ml ' .,miti \
lA 1)1 J-.K
I! IK I
•M- lAlIil-. I<
StMtc or luiniti \
3vH roo'A
M"ntli> /T I Day* (Vi-ar)
iii;MP:r.v ci;i<tii-\-, That r atu'iiad .1cihmsi>(1 fn.m
\5 i(,oH to (wlv^/cv_ XH.
^
that I last s;i\v h^ , . . ,â– ,!!'
and that fUatli oihu ircil, <mi tin- datr staird aliov*.'. at ^
Uv M. 'I'lu- CAI SI'! Ol- 1)!:.\1II wa< as follows:
M
\M i:
<>i Miii'ii).; K
n'k rni'i,ArK
' I *<'ri' \i"ii>N
Dlk A'lK )N
C( (NTiv I i;r'i(
IdkATK ).\
)V(//-.s- MoulJi^ \. nays
/A
'/^/A"
)", ,/;
U/CLorv; J AXX/wc^.XL/a<j
I Signed i vD, n\. UkAX<l^
:C1AL l!M
M.D.
Special Information "niy for Hospitdis, insfiiiifjons, Trdnsients,
or Rpicnt Residtiits, and persons dyinq and) from home.
;/ / ' /;),'. ,â– wM O
); ,:
O V „'// 'X?! /'■•
I'll I-. \H( )\1': ST \'!'1-I) IM'KSON \l, I'AKrUT!, \Rv \ i;
in;sT oi' Mv isxn\vi.i;i)f, !•: and i'.i:i,n;i"
(liifir mini
y>o
Fiirmcr or
L'sudI Rpsidrnce
Whfn was diseasf ronfrrirted,
If not n( pidre of dfdih ?
How lonq al
Plarcof Dfitfi?
Days
I'l.Ari" ' ii in K 1 \i, < ii'
ubcrW. \j\.jb-<u^
\ 1,
a.
: K i;Mi .\ \|,
IM)!',
CV/Q OvId T90'\
npw^c^.-'^^Kav^K 4
N. B. Jivcry Item of irifor-ttvition Hhould h.- cjirctully KupplkMl. AdF. kHd ild be stJited F.X AGTLY. PHYSICIANS hIiouM
»tatc CAlISn or ni: ATH in pliiin terms, that it mjiy Ik- properly cliiH«it'ic«I. The "Spewinl Int'ormjitirjn" for p«r-
v.ins flylnji (iwsiy from liomo slioiiM be ^iven in every instiince.
Ii
' 'I
i: I
p
t:
Hi
â– â– *:â– â– .: I
If >
V '1
't
^
1
I
m
i
i:
WRITE PLAINLY WITH UIMFADING INK — THIS IS A PERMANENT RECORD
]U-\u\ ..f II. ••'! i- N"-
Iff W' IK'ic I' C<
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
■■[■■TWJl^M— »
Br(f/\s/('/'e(l J\^o.
1211
DEPARTMENT OF PUBLIC HEALTH -City and County of San Francisco
Certificate of £)eath
[ 11. 5. Stan^ar^ j
QD
J?
(3^
No, 3.
PLACE OF DEATH: — County ofO/CX/rv; 0 >UX^ax^A^'C{)City of C'/CXy^ru 0 ^^^/Cl/^-vc^a.^ t>^
CA)-^V Lo'UJvt) St.; T Dist.;bet. Axxxw^-^^^^cu and ^ij^V^-^^o. va^cv^-
(IF Dr*TH OCCURS AWAY PROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR U N Of R "SPECIAL INFORMATION" \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
CN^XXaajAX^^^'A. -^1^
- 1 \
I) A II
\' .]•
PERSONAL AND STATISTICAL PARTICULARS
ri Ml )iv
,'K III
M.ntlH (j
MEDICAL CERTIFICATE OF DEATH
DA'l'l-: ( )!â– l>\'. \ I'll ^
«tOl
5
^INC.l.l". M\KHII".I>
W!I>' >\\M-Ii ( »R |):\'t )'■'' )■[»
Jl
,1 /,.;/,'//
L
!?«
murin'i.Ao:
fst;fi, ,,i r,,initiv
\ \M 1- I )l
1 \'ni i.K
I5IKTIIIM
' " ' \rii I In
■I ^"' 111 r; • \
M \ IIM-.N â– ^: \M 1
<>! MitTillK
il' Kill I'l.All':
<"'iinUr\-
I (Tr \ TK tN
'H.iyi (Vi-ar)
Mi.iulit /T"
III;1M:!;N' t i;uril-\', That I altLMdr.l ilccrascMl fn.iii
li . ,,!iv. on Lm-a.o Ok'i
and i lial <K alli iir( iiin-il. ( hi t lu' dati- ^(atrd al)(i\-t.', al ^
U^ M. Tlu- CAlsi.; oi" i)i;.\idl was as foll.,\N
llial I la'^t <a\\
l.^oH
Lao^aax \hjJ^W\Ai.>v^
, s :
DC NATION )V,/;.v
coNTkinrToRV
//(>/// s
diration
( Signed )
)'<â– (! rs
JA';////s ^ /l/]<
M.D.
Jj Ql)
Ua^qIH r«)oH ^Addrrss) IXCl IU\A.^>\ Ui
SPEcftAL Information "nly for Hospitdls, institutions, Irdnsients,
or Rfu'iil Residtiils, diid persons dvin) .mii) froii tionif.
Tin-: XHON-I-: STAT i; I) l'i-.Rs,,»\ \i^ I>,\k fhl l.AKs \K j- V H r }■I'l > ni 1-
iu-:sT (n- Mv KNKwi.i;!)!; }â– ; and hi-;i.!i;}'
Former or
L'siidl Residrncc
Whrn w.)S dispa^p r onfr.n tpd,
If not fli pli»(p of dp.itt» ?
HoH lonq al
PIdfC of Dp illi ?
0.1 \s
(Itifoni'iiit
>\
UO^ojL^JL
\ ' :!.-s % vl/X^\>X^J ^^^-O-VA^t
•i.A<'i': ( )i la k I \i, OR !<i;Mt >\ \i.
i> \i'i
VI 'I k i;m( i\ \ I,
0.(0 T90H
I'l. \< !â– . I )i ia k I M
^- '*• Jivery item oif iiifr)rmTition Kli-mld hj ^airctully Kjpi>li'^«l. AfiB whrjultl be stntetl HX \GTLY. PHYSICIANS hHouI.I
«lJitc CMJSF: or 1)1. \ TM in phiin tcriiiH, tluit it mjiy l>w- prop^^rly cInHsit'iecl. The '*.Si»cciol Iiilformjitirin" for per-
sons (!yin<i nwny iram home slioiiltl bt- jiixen in c\cry instnnce.
VVH
•i
t
li:-
I
I
( '
I i
.M
»;
?>''
,v\"^V
â– ^\-
'.M
^ I
■«
771
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
!;..:n.i .,f llciini' 1 \'.
IKtI'Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dff/c r/fcf/.
L^a.^voaa.<lX QvS^
Jf^O\
lie <^i, sic red jYo.
1212
.V
DEPARTMENT OF PUBLIC HEALTK^City and County of San Francisco
Certificate of IDeath
1 la. ir. J^»tan^ar^ )
PLACE OF DEATH: — County olQjO^JW^ OAXXA'VCAACcCity cf O/OUVu 0 AXXA^OoayCC
N
o.^H^
/CX^4 VA^A^CVVt", y V
St.; d\ Dist.; bet.
and
Axiv^rwL
(;r ntATH OCCURS AwftY FROM USUAL RESIDENCE give facts called for under "special INFORMATION" "\
IF DfATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMDER. J
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
Cr-1
i> \ i!-; I '1 i; ; K i'
\' . !â– :
! n ! 1'
1 rl'\'\
as
1
II
/'.
SINCI.l- MAKKIIIt
U'llx A\i- I t 111.' t 1 â– \ 1 ii' . I ' I
I W ; i I . â– â–
IMKTl! !'l. \.' !•
!• ATM I'.k
I'.IRIIIIM, AD-:
<>i 1 aiiii:k
"^t:{li . .1 i.', ,uilt I V
<â– ; Moriii'K
lUKrnri, wv,
or McTlM-R
â– I '( iiiiiii \
VAJ .'OlA-'Vv^
I'A rioN
A'' â– /(/c'l/ ,â– '/ .Si, '/ /';i!i^ â– >('(
MEDICAL CERTIFICATE OF DEATH
DA li: « >1 Dl.AllI /-^
M.Milh' n
\ l[i:KI';r.\' CIIRTU'W TIi.U I :itton(UMl .lic.-asc-d limn
lc)0 to i(,o
that I last saw h alive- on iiyo
a:i'l that iKath i tci-u rrcd, mi thi' tlai.c s(afL-<l ahovf, at
M. Thr CAISI-; OI' I)i:.\'ril was as follows:
])rK \ll( )N
t'ONTU li;i'r< )R\'
) V./y
.!/<'/////.?
/)ins
Dik \ rioN
^
} V,.'/,v
JA"////.s-
( SIG
NED^ J.\JUiXA^v^OVl J. VOy-v
LLu.A.^s I on'* (A.Mnso bC)b dxctbi/u at
EC^AL INF
1
. 1
1'
1
i
1
1
1
' 1
:|
t
f
â–
i
/,-.'//. - /),,•!
iiii'. Mtovi-: sTAii: i» im-:k-;onai, par rini.AKs ar i. i'r i)': to tii r
I!i;ST OI' MV KNOW i,i;i)|-.}.: AND lUll.IJ'.F
(Infi.-niaiit LAJ CT^^-'^X^
U'lilrc
o \A3 'Ouv^-CaJLm vJLol/^lA
Special Information <»nly for Hospitals, institutions, Ir.jnsients,
or Rpicnt Residents, dnl persons dyin ) dw.iy from home.
Fornifror Oc,^ \l\ 0 . A, How lonq ,it
lSu,il Residence OT(k UJ/OuftJk/^\. ^t Pi.ire of Death ?
When was disease contracted,
If not at plar e of death ?
I'l.Aci-: OI' m RiAr< OR ki-;m(i\ai, I nxri;..!' r.rui.M. >.i ri:movai.
iNDi'.R I' \ki;r \X)
4
f
(Ad.;
A.A'VOl 0-A..a^-\^
I CSS
^IS. ^^Lxx^, ^t
iN. K. F.vepy item olt hifiirmition should b.- ciiroV'tilly siipplieil. X'JF, .sh'>,ihl he stnteil KXXCTLY. PHYSICIANS Khoiiiti
state CAUSt OF DliATH in (>l>iiri terms, thnt it m:iy ho properly cliiKsil'ied. The "Spcwinl hiVoriiiiitlon" for per-
sons flying nway from homo Khoultl he i^iven in every instiince.
â– 4^^
Pi'
)•'
\%
'm
I Hi
.L
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
IJo.'inl ..f Ilialtli -I- N(J. 1^ *-:;'»>A' hSiV Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/)((/(' Fi /{'(/, LLv^^<y\-/^AAj 'Xk)
n)o\
Be^Lsleiecl ,jYo,
12\^
\
Deputy Health Officer
DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco
Gcvtificatc of IDeatb
U. 5. StanDarC^ ,i
^ ^
%
(^
PLACE OF DEATH: — County of C)'CL'>^' 0.\XX^^^:i^ACoCity of 0/CX/>v J X.<X/->^./c.a-4. c^
10
Ne»^^^xUv<xAj vryy>JiAj^jb-Y\.<i\,\
CKLl
(IF DEATH OCCURS A)^«V FROM ulSUAL
IF DEATH OCCURRED IN A H o(e P I T A L
kuJ^
Cul Dist.;bet.
and
RESJDF NCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION
OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUVBER
- )
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
II 'I.I iK
^'^^ ^ ft
DATi: (•!" I'.IKl 11
)/v^<xcL
1
MEDICAL CERTIFICATE OF DEATH
DA TK oi' I)i:a rii
IH
\>.i-;
11
1 /-.»/"/
•^iN* i.i" M\Ki<n-:i)
WIl»i >\V)-"I) nR l):\-i I'.-, IT)
r.iK rni'LAcM-:
St.'iti or C'Minti V
M.>Mlh> A
I lli:m;r.\ Cl.kTII'V, rU.a I aUtn-lcd ilectascil fi-Miii
'I):iv' (Vc;ir)
â– I (j< ) â–
t(i
tlial I last s.iw h
'alive oil
•1(,0
^^^)0
iihl that death < xTurrcil, on i]\v tlatc stated alto\-«.-, at
~— M. Tlie CAISI-; Ol' DllVl'il was ;,s follows
CX_^>
v-v
NAM) (»!
fathi:r
HrRTHlM.ACH
ni- i-ATni-:K
'Stat I.- or CdiintT V
M XiliJ.X N \Mi,
<'l Mol'lli: K
lUKIHTM.ACK
«•!■M(t'rin:R
(Slatt : i".,initrv!
<X/>^'<:L
DC RATION
}'r(7js
Mouths
Pays
Hours
coN'rKii;i'i-()k\-
DIRATION
)'<•(// 'V
X\/W(PrV
AV
d-
^(JAD (Vy.^^.^uJkxJt^'^JlK)
occrrAiioN
- .Vn/////s /),!]
f Signed ) Lc\^mJl^; J. vj.Uj. IuiIolaviL
U-^^CtX5" T,,oH f Arl.lr.ss) M3:\|n^JlA^
//o/n<
M.D.
ii
In '.
THi: XUOVl-: ST ATI, I) I'KRvoNAI, I'A K T If I " I,A KS AK)! TKI i: r( » TW]-.
l!l<;s T OI" MV KV< •\\I,i;i)(*. K AN!) lU-.MllF
(Infovnintit
Vj OL^t^wA^cJ^ Uj
l\'hh<
SPEcCaL Uniform ATI on nnlv far Hospitdls, In^firutions, [ransienls,
or Recent Residents, and persons d\inj dw,tv Iroii fiome.
Former or le-Q ^ J ""A -4- How long al \
Usual Residencf Ion a.AJ./vvJ2A> OX Place ol Death? aJ^Wa .. Pnys
Wfien was disease contracfed,
If not at place of deatti ?
I'l.ACi: 1)1 IHKIAI, «ik ki:M(«\\I.
rXl/llKTAKllK
I kl'MoVAl.
'-Xl I90H
(Addrc
^' B' Jivery item of information should be ctirafully «upplic«l. AflK Hhoultl be «tateil nXACTLY. PHYSICiANS should
stntc CAUvSn OF DfiA TH in plain tcrm«. thnt it may be properly classified. The *'S}>eciiil Information" for per-
son* dyin^ away from home should be ftiven in every inHtnnce.
if 1
ii
m
â– J
ii>
f,f.
â– ( 1
:l(*yi^- < •-
ki^ ->
'M
11''
*fl^
'i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
HoMi'l -f !h:i!th 1
s r-'^'^-ntv, IKS: !'(.•< )
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I)
((/(' Filed , \X<^^yo^A..^J&J
3.(0
1V0\
Begisfercd JVo.
IS1
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
(Icvtificatc of E)catb
( 11. S. *5tanC>ar^ j
PLACE OF DEATH: — County of O/Oy-v-v 0 .VOlao/^^uloc City of CJ/Cl/Vu OAXXA-L/C^-Cbec.
M:^,. UXm,^ Ww>ni::u do CkU^a1x>J.' Su Dist.; bet. and )
(IF DEATH OCCUlTs AWAV FROM USUAL R E S I D E N C E C I V E FACTS CALLCD FOR UNDER "SPECIAL INFORMATION" \
IF DEATH OCqURRCD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
,/TV
^i:\
i>A ri'; < ii- i;iKTii
PERSONAL AND STATISTICAL PARTICULARS
r< ii,( »R'
KjJi
cJ>Jb
M..iith
.\<; }•:
CU
It
:j ij r
1)M\
yi.nillr
l',l^
•^IN<. I.J". M\KI<Ii:i>.
w i i)( \\\v I) ( >k" r I '\'i ii' â– "i' ()
i
-^^^cy^
^.
MEDICAL CERTIFICATE OF DEATH
i» A ri-; 01 i»i;a 111 ,0
\^WVAyVJ/v-A.Ai.A/ c/vl
â– M'.iit !i I A 'I);iv)
IQO 4
1 III-, k i:!;\' t Ijnil'N, 'rii;it I .iIK-ipIimI (IcccHscd from
that I last saw li <^* ' ■•. ali\ (■nil vAAA^Q 9^1 loo ^\
aii<l tliat <kath (khu rretl, mi \\\v daU' stated altovt-. at b- -^ ..^
U M. 'I"lu' C.\I"S1<; ()!• DI'A'rH was as follows:
\ \M )â– t '1
!• AIII \ M
lilRI'IlIM, ADv
<>!•■I A iiii:k
•St.itc or (."oiuilT V
M \ll)|". .\ NAM 1.
ol- .Mi'TIIl'.K
i!iRTiii'i,Ari<:
Of Mo'ini-ik
''0UIltI\i
' '''ir.x riox
Vo
DIRA'IMON
Mo)ilh<^
vouL'CCYv
d/OA^
A'/'- !iil l! ill Si! I' / I ,â–
/>XXV
fhn
I loiiy^
DIRATIOX
^
)V(/;-.v MiDilhs
Hays
XJL>>
n »â–
1/ */.//;.
(SIGNED^ J . VJ\. db/OAt:
1?^ rc,oM rA.l.]rrss)UX'Lt^^O JW^vX
SPEClJAL INFORMATI
or RprrnI Resiilt-nts, and persons dyin-j .ihhv frmi home.
iON only lor m)spitdls,
M.D.
<Xv.
Former or
L'sUfil Residence
nstitiitions, frdnsienfs,
Ut) UU/WV«yT vt OlDotllf |,,re ol Death ?
\
Days
When was disease rontracted,
If not at place of death ?
rm: nhdvi", stati: d rKK'Sowi, i'.\i< ri(ri,.\K-- \kj. i'ki i. i > > i in.
lii;.sT <)!•■MY KNn\\I,i;i)C, K AND Hl'.I.Il'I'
r\<i,
I'J.ACl-; (M lilKIAI, (iR R}'.M(>\AI,
;rtaki:r "jVjLULu^^ ob Ou<Vo-^»^
I» 'ill' '<'■!'.' Ki.\!. «j[ R );M( i\' ai.
T90H
\iu:
' --a*
^' '*• F.very Item o4t inV'ormiitinn shoiiM b.- csircftilly supplied. M\F, Kho.ild be Htiiteil F.XACTLY. PHYSICIANS Kboultl
Htiitc CAlISi: or DliATII in pl;iiei terms, thut it mjiy be properly chissified. The "Specinl InV'ormnlion" tor pur-
sons flying nvvny from home should be ftiven in every instattce.
!F-
H.I
' «
' i
i:^
;t
H
' I •. I.
ll
l>
I
!i'l
^^m^"^
w*>'
•W"^
:1,
T
I
I
' ' â– n
r-it ' ^
I.' It
lf>
V
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
n.):ir<i of H(.!iiih I" No -- '^t:yj^-' '*'*^'' ^''
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
pN/r /7Av/. CL^MX^oCLt) lb I'^OH
P oT
Jie<^i\s(cre(l jVo.
Jlrr^iO
I
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccitificate of IDcatb
PLACE OF DEATH: — County of CJ/CUyvJAxx^x^^l^cc City of Cj/tX/>^ vJ^<Xy>xyc.A.^^c
No. a LU/CLU'dfc
(IF or ATM OCCURS
IF DCATH OCCr
Y HnoM USUAL RE S I DE NCE give fac
RWlto 101 A HOSPITAL OR INSTITUTION GIVE I
FULL NAME
4^^' St.; X Dist.; bet. cLuXA^J^AUA^trXtJk; and dlS^i-cU
TS CALIED FOR UNDER "SPECIAL INFORMATION' "\n
TS NAME INSTEAD OF STREETT AND NUMBER. ' /
PERSONAL AND STATISTICAL PARTICULARS
\
'VA
n \i'i-; t>i i; IK I'll
At.!-:
,l5t
SI
M.-mlii
\
it.i\-
1/.. ;/.'//>
(Year)
/.',/
(VCMI >
"-INt,!,!.:. MAKKIi:n
' Wtiti- ; II ■-• >iirr -'at ion '
1 St:itt nr •.■|>utltl \- '
N\Nn or
lURI'UI'I.Xt'H
')i- 1 \rm-R
\
(
'4
Jj
Ok
? f
M\il>I",X N\M1'
O!' MoTIli: K
MEDICAL CERTIFICATE OF DEATH
DAIK »»!• I)i:.\TIl /O
(Motuli) jT (I)av>
I ni{UI';r.\- CI;RTI1-V, That I attciKkMl (Iccxasc-.l from
AaXm U I90M to LLa..a^ 15" l(,oH
tlial 1 last saw h -t- v% \ alivt- on v-\.Aa.>C« "^^ T(jO H
ami tliat tk-atli i iccii rreil, on tln' d.itr stat«.-<l almvi', at I VJ
vl., M. Tlu' C.\ISI<: ()!• I) i; A Til was as follows:
Dlk A'l'loN )',ai
CONTRll'.r'roRV
Monlhs
/\n's
I /oil
rs
r.IKTIII'I. Ai'i-:
''I mi»:'!Ij-:r
Sl;itr I ii ('( 111 lit I \
1 ri-1
\jXxDo<jjtx>
<X/^"vC^
!) r R A '!' !( ) N
SIG
)V.//
NED ^ G). dj.
M.D.
Vu^-Q Os^ i(,oH rA.Mrrs<) bO b 0\JtCL^ywA^ dt
SPEcflAL INFORMATION only lor Hospifdis, liistifu(ion<{ Transients,
nr RtrenI Rcsiilcnts, .iinl iicrsons (|\iii| .iwav Iron home.
Mull:
l',:^
Til I, \Hi »\i-. sr ATi'ii ri--Ks(>\Ai. TAR Turi.AK-^ A K ) : i'kr i-: r< » VW V.
I!1>T (»1- .MS' K Ni )\\Ij;i)C, )<; AND lU: 1, 1 1", I"
( 1 nf. jni:iiit
\ l.lrc'.s
1^X0 U^.Oi.^t^a^ CJ,
*
Former or
I'siitil Residenre
When was disease rontrarled.
If not at pla(e of death?
fl(»»A lon(| at
Place of Death ?
l)a\s
ri.At'i-; < »i' liiKiAi, OR in:Mo\Ai,
-t
INDl
i> ATI': III !!• KiAi. 1,1 ri;m(»\- \i.
J ft (p 0
>"'• B. Rvcry item ot' inltormiit ion Nhoiilil he ciirefiilly siipplie«l. ACJB slioulil he .stiite«l liXACTLY. I»ll YSICI \!NS should
8tnte CAlISr OP DTA TH in plnin terms, thnt it msi.v he properly clasKified. The "Special Int'ormiition" (for per-
sons dyin^ away from homo should be (X'^e" '" ever> inHtnnce.
:t
*Pfr
I,
^^
■M" • i
"^^fl^^A^^^
A '? -^.J
•-(>.
'*"i^:
-. i,'r,
'i
â– .*t , t
' >
â– J
;
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
i'.Mar.l of Health— F No. is t-^rS'-- H^il' Cm
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
!)((!(' Filcil. LX^.v^avAXfc g.b l'^()\
Jlegi^tei'cd J\^o.
1216
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Ccvtificate of IDcatb
( 11. S. Stan^arD }
3 % SI
%
PLACE OF DEATH: — County of Vj<X/>^j J AxX'-wCA-axu. City ofvJ/Oyw 0 /ux/vv<::A^a^eo
No. H'il V^-<^Vi,
IF DEATH OCCURS AWAY
IF nCATH OCCURRED I
St.; IC Dist.;bet. IH
and 3vO
"u
FROM USUAL RE S I DE NCE GIVF facts called for under "SPECrAL INFORMATION" \
N A HOSPITAL OR INSTITUTION C I V E ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
X^K'
PERSONAL AND STATISTICAL PARTICULARS
ft t. < >!,( iK
[)l
<xJ
-O
JjL
I) ATI-, < >!•■I;IK 1 II
Ai.F.
1
HH
a
l):i\-i
M.nilh-
It
U'; i: ' -11 - ii i-i ' ;iat ii 111 )
luurm'i.ArH
' Sl:ii < I .r < ■« 11! lit r\'^
I- A Til 1,1<
lUKTIIl'l.MK
n|- ! AIin-K
ISfatr iir t'oiinlrv'
M \ I I)i: \ N \M i:
<>1- MMllil'l;
iiiK I ni'i.An-:
«>l M<'TH!:k
â– ' ' ' ' > â– .'lilt : \
MEDICAL CERTIFICATE OF DEATH
as
T9o\
(V.-ar)
'NTontli' \\ (Day
1 III-:R1';1!\' CI;RTI1'V. Tl)at l aUeiKlcl dccLascd inmi
~ I9O to
lliat I !a^t saw ll "" alive on -
I()n
T«)0
aiiil tliaf ilcalh oith rtfil. 011 tin- i\\\W statt-il aliovc-. at
~- M. Tlu-CWIM': Ol' l)i:.\TII was as follows
^XVVi-'wCU CO-vv
qvvJjuIv^jl U.^U^^ AI )Xct\xxA UaJUnJLcuv JUAj(iii.<x-*-<.
I )r RAT ION )V«//-.v
CoNTKNMTokV
DI'kA IK >\
( SIG
Mouths
Par
Hour
Moil //is
/hivs
Hours
M.D.
<K\) r((0 1 {
SPECIAL INFORMATION '"'ilv for llospitdls. Inslifutlifls, Transifnfs,
or Re(fnl RcMilcnls, and prrsons dvinj <iwdv fron home.
lA.v///
/',.
Ill 1: V ii, )\ 1; si- \rj.;i» i'j<: i<->oNA!, f \ k ruTi. \K> ax i; TKi- 1:
r.l.sl' oi M\ KNo\\l,i;i)<".H AM> lU-.I.Ii;!
'Inf.,!,., Ml VJ /VCX/V^
'I' » 11! 1:
( \.l(ln
HljQ,
formfr or
L'sucil Rpsidcncc
When was di'>fasp rontrarted,
If no! at plafe of dpafli ?
HoH lonq af
Plat c ol Dralfi ?
Days
ri.Ari". 01 nrki \i, < ik k i:m< >', \i.
i» \'\'v <\ III I.' I \i, <.i k i:m( i\" \ I,
vAaavc\ al
I90M
N. ».-
-Hvery itt-m nt' infornml ion kHouIcI h.- cjirolfully supplkti. A'lK «h')ul«l be ntiited li\ VC Tl.Y. Pil VSICI ANS Hhoiiiti
HtHtc CMJSi: or D!:A I'll in pinin Icrins, tluit it rnjiy ho pi'..pcply cItiHHiricd. The •\Spccijii Int'orinutioir' for p*r-
Ron* (lyini^ oway from home Nhotild be ^i\en in every inHtnnce.
«
V
I
%
r
i..
« •
.' I
^ . I
I
f f
r1
Ml
'i.i»:£-
4V
r
It I
'M
m
\
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
! 11
t ^.
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
If)f)H
lie^i,s(ri'C(l jYo.
1217
Deputy Health Officer
I hdfc Filed , LUwAXy^^LAA}
DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( 11. 5. 5tan^arD )
o\\j0^nc\j 0 .VXWuC^'CC City of vJ/CU^ryj 0 ./VXXa^u^a^^cX)
r>k),
PLACE OF
(
DEATH: — County
IF DE
IF
\a.^\Lm vUc/VVVAyVVCrix^LSt.; Dist.; bet. and
ATH occurA away from USUAL RESIDEr^E Give facts called for under "sPEcrAL information" \
DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OK STREET AND NUMBER. /
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
V < •!.< iK
DA n: I 'i i;iK I'll
\''. !•;
^
hxM-
M.ntli)
lb
(Dhv)
\d\ ).,/' Id
5
/ ',/ 1 .
siNT.i.r M\Kuii':i)
\\\\M IWI- I) OK Ii5>( )K(.i:i)
' \\i ;!â– in ->ri;i ' KiliDii)
inKTui'i. \r )â– :
( stall â– r; I â– . r, i;! i \
\\M1-; nl
FATH i-:k
HiKTii iM \ri-;
iw iArin-:u
(St;ilc iir v'<Miiiti\i
M \ll)i:\ NAM !•:
<'i- M<>ini;R
luR'i'niM.Ai'i-:
<>i- M<)rni:K
'SlMli- 1)1 (.'olilltl \- '
MEDICAL CERTIFICATE OF DEATH
DA I1-; oi- Dl'.ATII r\
'M'Milli) K (Driyt (Year)
I m:RI-:i5V CI-;RTII>\'. Tlml r .iltm.U-.l .Icreased fr.mi
0-C T(p \
10 i.)oS
that 7 la^l ^a\v liA, • i alive on
^ ' ' ' ' '" vAa>\ux
and tliat (Katli < xaai rrcd, on tlu- <la1«- stati-il ahovr, at ll HO
a
>r. 'riu' CWl^^l' Ol" I) i; A Til was as follows:
CWurv^v^ Ljl^JLA^'Va.i aavtx^-
DlKAl'ION
)'(V7/.s- 1 Moulhs I I /An.v
Hours
C<>NTR!i;i"l"(>RV
/
1) I â– R A Tl () N
)'('(} r
J/("////,s-
/\JV
<>*ri TAIloN 0 Q
SIGNED) Uj . V) . W»X<X ' >x.i
I lours
M.D.
V4J1
Special Information "nly for Hospitdls, institutions, [ransients,
or Recent Residents, and persons dyin!) .m<iy from home.
former or
Usual Residence
\XX/Y\f>J^
How lonq at
\0-LA-<UL Place of Death ?
Days
f\'' nil! Ill Si!!' / ii!i/</^-'o
r,-..;
,1A-/////>
/',n
HI". \M()V|.: ST \ri"D ri'KSOX \l, I'AR TirCI.AKS A K ]•; IK I i: It ) riN-
in';sT ()!• M\ kn<)\\i,i:d< .]■; and i'.i;mi-:i"
( Infrii in.iiit
o^vcLAOk LL.
Ox.'
k\<L
\.Mr.
LAjLA''\A-,^jA.><yVVwa...<L
When Has disease contracted,
If not at place of death ?
I'l.ACl-: OI' IHKl.M, OK K1:mm\ \|,
'">
!) \ 11
j\jLiXM ^^ (h •'
â– I lAi or ki-:mo\\i.
TQOM
r N D I", k r.\ K ]â– : R J OC-VA^ "<V UVl) ^XCl -CV/^y^^
!***• B- F.very item o? Information should l>- cnrePiilly supplieti. MW. shoultl bo .stntcd RXACTLY. PHYSICIANS nhould
«tate CAUSE OF DFIATH in pluin terms, thjit it miiy be properly claKNilTied. The "SpecinI Informntion*' ?or p«r-
pons dyinji away from home should be feivcn in every instance.
I'
J ,
. ;
1:
i: «.
1^ ).
k^^f
'I
». I
^1 '
«
I
1
• (
...
"TWK
Mti:
i
I
"
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
n i â– N '
/)((/(' rih'fl , [Xx.^xx^<aX x^
cL^CrVovu^
Deputy Health Officer
lie<:!i\^fcre(l A^o.
1218
DEPARTMENT ()F PUBLIC HEALTH^City and County of San Francisco
Certificate of IDeatb
( 11. 'Z\ ir»tnnc>nvD
Q^
^
PLACE OF DEATH: — County ofO<>.n^ 0,V<X^^/tA,^x:(City of C)<Xo^ O^VxDl/yvc^x^-c-o
-14*
No. ?)bn.':L - la Ik
(I r DEATH OCCURS
IF DfATH OCCU
St.;
M
I
Dist.;bet. 0.uJ7v\XA^
and
P
crL^\JU.
S AWAY FROM USUAL RESIDENCE give facts called for under â– SPEC
RRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREE
^
lAL IN FORMATION' "\
T AND NU MBCR. /
FULL NAME
J 0-CvA^^
PERSONAL AND STATISTICAL PARTICULARS
>i;\
^
J-O^o^oJU
mi.< )R
,t.
i).\ 11: < '1 !.;;< Ill
\<.i-;
M..n
\J^
^iNt.i.i: M\ki<ii:i>
\\ii»« )\\i' i> ( »K ii!\"t »k\ I-; i»
iMi-' rniM. \'-i'.
M.'itc ( 1; I â– ni nt I \
I" A Til I.k
i;iK 111 I'l, \i 1-;
<»i i\rin;K
' '^1 .lie I If ».'' .imt 1 \
^1 villi, \ \- \ M
I M M' >T1I 1 !â– â–
HIKTUI'I.ArK
"I MoTHKK
' '~l:ili ' .1 Ooillltr\- 1
MEDICAL CERTIFICATE OF DEATH
DA ri", < >i in; \Tii /O
'M"iilh> A 'Dmv) (V. ■;(!•)
I iii:i<i;i',\' ri.in'ii-N-. 'I'l!;!! i .iitiniUd .loco.iscd iinin
- (..
i(/)
that I I.i'-I s;i\v h ,ili\i nil "~"
.iii'l lliat diatli occiinfil, on tin- "late ^talrd altovr, at
1 ( f)
I(>0
M 'I'lir CAI si: 01 Dl, \l"il wa-^ m'^ follows
1)1 k \II( »N )'(iirs
C < >N Ik IIMTOKN"
Miuilhs
Pii)
'.V
JIo
tl) <
IH RATION ^ );<//
1^
M.'nlhs
\Jir\Jrw\SJ\j o.Vj.vU).~Xil
l\l\
/ fiili I s
^SIGNED) V.^X^J^'Xil^ J.VJVUJ. c:UX<:U'VA.dL M.D.
V'^ i.,oH u.i.ii.-.^) Lcâ– VCrvvil^^ U^iv^J.
Special Information "hIv tor iiosiiiidis, insiiiuiions, irdnsimis.
or K('(cnl K<s|ilcnls, .ind persons dvin-j .mny fron h'lmc.
I\'li{f':l III '^flll I I, nil '-I'll
\< 'Itl,^
f ormfr or
LsudI Residenrf
Whrn HHS discdsp (onfrdfted,
II not dt iddir of dfdth ?
lloH long dt
f'Idi f of Ih'dtli ?
Ddvs
Ml. \H()\i.: sr \i'i:i) i'i':um>\-Ai. pxriuti. \k-, \ !• \
i!i-;sr «ii- Mv KN< )\\i,i;i)c,i.; AM) i5i;i,ii:i'
vv
nl
\J2\^r\^jLy>^
.^<u^
\.!.!i.
I'J. \> I, ' >1 I '.I K I \ I, iiK 1; !.M( i\ \ I,
n
) \ II
I M'l
' I I M â– I K l,M< (V \1,
looH
^tVAA^
^' K. r.\'.ry item o(f infirniiit ion fihould h- .. iirciriilly Hiip|>II<-<|. Adii hHohIcI lia Ntiited I.X ACTI.Y. PHYSICIANS hIioiiIiI
Mtiitc CAIISi: or ni A III Jn philn tcrtnM, that it miiy Ik- properly cluNNirictl. TIk "S:»cwiiil Itn'o
!>cwiiil Irtt'orinfititiri" for
son* «l> inji iivviiy from Imitic Nhotild be ftiven in every inHt»incc,
pwr-
\\
';
I ': I
(
!<'
< I
tl
^
' " I I '
III I |.,^
1.1
I
.a
7f 1^ f'W
m
f
y !
'\r
t
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REPER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
..•iv'l •■(' II -ilth I- V- :- -^-'-/^^'-i- 15M' (
/)(f/(> rifrd , \XK^^\y^Ak. 3Ho
n)o\
BegLslrred jYo.
1S19
i.^il
Depuiy ("ieaith Of«lcer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeath
( 11. 5. 5tanc>nvC> i
PLACE OF DEATH: — County ofC'CLA^ J AXu>\/Cui.ao City of 0/CX/>^ J AyOu^v^^uOu-co
No. ml
St.; S Dist.;bet. lb
and
n
ti
/â– IF Df AT H AoCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPrCIAL INFORMATION" \
V IF DEAfH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUVIHER. )
FULL NAME
X^
VOU
XXJjir>rv^
?
PERSONAL AND STATISTICAL PARTICULARS
I C()I,< iK
W
kXjl
1) \ 1 1 ( 'i liik'i'ii
H
( Vtar)
<x<^y.eA'
MEDICAL CERTIFICATE OF DEATH
DATi-, <)i i)i;.\Tn
vXla^<
(Yc;ir)
n
)-.
a-^
^INf. I.l" MARkll'Ii
\\II»i »\Vi:i) < IK I»!\ttKMj:i)
Wiiti-in SDcial <UsiviKiti<)ii)
M^-<rv^^J^cC
r.iK iniM. \t-i-:
stat<- iir (.''Hint I \-
\ \M1. ()1
1- A III i;k
HI!-; lii I'l. \i- 1-:
oi I \ ; in: K
MA I 1)1;n N \ M 1,
111' MitrilKH
luRrni'i, \' 1.
<>i M(>riii-,K
<Sl:itc i»r Couiiti \ I
i^
Month) /T 'Day)
I MI'RI'il'.N' CIK'III'W 'I'h.it I ,ittiii'K-.l (ItHvascd fr-.m
tliat I la'-t --aw li -i.-"\ alivi'oii vAA.^wO_ 'Xb l<p'\
aiwl that tlratli < >ccii rii'il, nii tlu- tlati' statcal ahov*.'. at i
vJ M. Tlu- CAlSI-jJM- l)i:.\'ril was as follows:
.^-vx,^^^
>-v
i'A'no.N"
(J XX^'\'VCX^AA^
f i '1 »
UXh^/YW<X-v^
DC RATION O )V(/r.9
CONTRlI'.rinRV
Moutir
f^avs
//i
ours
1)1 RATH). \
( Signed )
)( >l I s
Mi^ittlis
/)<71
vs"
i
//om s
M.D.
1
Special Information '»niv t^r iiospifdis, insmutions, rrdnsients.
or Recent Residents, dnd persons dyim) <m,iy from home.
);â– ,//â– *- 1/ ,;'//.
/'./I
ill 1-. XMOVK ST \'n:ii I'KKsiiN \i, 1' \K lirr I \KS \k j; | ki j i , . rm
r.i-;s'r oi- my knowi.kix.i-. wd mi,!! s-
III !•'! man I
^?fw. Gv OJUU^.
•A>w>V.
\.'.l'. ^-
n'^?.
\Jj A^HktX/^
^1 dt
former or
Isual Residenrf
When v*<js disease (onfrarted,
II not .it plHieof denth?
HoH long dt
PIdrp ot ne,ifh ?
Odvs
ij.Arj; (.1 i!ik I \i,,()k hi-:m"»\a:.
ilVlji^of llii.;i\i. Ill KJ:M(i\ \I,
'^0 I 90 ^
0 <3u-rv W^J^
1 NDliKIAKI-lR I) V) . 0 . O-oJrUV "^ ^
A, I. 'I
!*^- B. r.very item of lnformfit!on hIiouM Iu csir-ct'ully siipplieil. >\\\\\ Nhould be stnted K\4CTLY. I»ll VSICI \?^ S Khould
HtntL- CAUSI: OP DIIATH in pfnin terms, thnt it mjiy he properly cliiHHiliied. The "Spcwiiil Information" for per-
son* (iyin^ uwfly from home should he (^i\en in Q\cry instnnce.
i
< : Ml
• y
> '
i'<
4
< J
I
1^^
c
%.
i
rr ' •
m !
1
I
• .V' ■' ^.
'.â– A^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I
P»
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I fhf/r Fi/cf/, LuAXyLA.A:tr aia J'U^H
llegi.slcred jYo.
A.<^f^\j
dJL/\>\x Depu
OfHc^er
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeath
PLACE OF DEATH: — County ofCj/CVru J A^O/wxr^^C^City of OxX^vu J AXX/>-lA1a_-^ <i.o
N«. WXaX'
(iF DEATH OCCURS
IF DEATH OCCU
C^v-(^cx\u. St.:
Dist.; bet.
and
s AVA^AY rROM USUAL RES
RRED I IM A HOSPITAL OR I
FULL NAME
IIDENCEGIVE facts called for under special INFORMATION' "\
NSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
A.A^A^^,
PERSONAL AND STATISTICAL PARTICULARS
-i;x
;> \ ii: (M I'.iKi'ii
\' .ic
â– '" (Ul
C-VA^r
/
l5a
M. M'lll*
sivi.i.i-: MAkKi!-: i>
\\ii)(»\\i-;i) OK i):v< iK*. i;i>
(Writfin sociftl (hsiKHation)
r.iKi'iu'i. \('i-:
•^t^iti It! f' imilr\-
I);i\i
.1/..;////.
> t ar
/',/i
MEOrCAL CERTIFICATE OF DEATH
'M-nthi K I Day) (Year^
I III'IRI'P.V t i:R'I"I!'V, Tliat I atten(U-«l .leroascMl from
Ho UyoS to L1.A.AX21 Qvt KjoH
that I la<t <a\v li <La-va alivt.' on LAa^\.0], '2L 5" Up H
aii'l that (Kath ocnirrcil. on the dati- statL'*] alxivr. at ^
^ M. The- C.MSI-; ni" DI-.ATII was as follows:
<-^.
.\^
SWW ()]â– â–
lAllll.R
U\\< I'Ul'l. \r 1-;
oi" I AlllJ'k
;s|,-iti iiT ri.iint ; \
"I Morm: K
MIKTIIl'LACK
in- MOTIIHR
(State or Country)
\y"\A^Ou
(Prvxi Mj|/o'V\;
Qjub
or RAT ION
I }\'<irs n
Mouths
/hiv.^
IIou) s
c < >N'iRn;r'r()RV
i)IR.\TinX )'c,irs
Mi^nths
l\n
Hours
Ri--iiJt\l III Siiii /'miiiisiii dk 0 )'(/.'â– â– Miifti-
(SIGNED) LI). CD-VJcrcrVJ. M.D.
Special Information only {or Hospitdis, institutions, irdnsicnts.
or Recent Resident*), and persons dying away fro.n home.
j (I
. i
I:
,; I,' â–
?!
t. '
s
!l|J...
i '
Former «r (y P (^ 0 ^"^ '""'' •*' L/
Usual Residence v) -^>a^<j-V^ \^oJ0 pjare of Death ? lO .. n
Days
/'./!
riii', \no\-i': si'ATj-n i-kksonai, rAK'ruTi.Aks aki; I'Kt}: n > rni-:
in:sr oi- ms' knowij:!)*". i-: and in:i,ii:i"
'Info; niaiit
When was disease contracted, ( f i) [ i)
If not at place of death ? VJ -V^x.O^U. VO^l'
1M,.U'I-: <tl lURIAI. (Ik kl-:M(»\"\I,
9 <X^v VnXcJtx^ Co
l»\'ll-;ot' I'.iin.Ai, or RIvM()\ Al,
C^-^A- .'3wW... T90H
'\.l.lr.
'CXXlA.XX^^v-vAJl.
-*^^ d:
1
1
M. B. Kvepy itom of information whoiiltl l> > carefully s«ipplie<l. A'lK shoultl be stalled liX \CTLY. PHYSICIANS shoultl
stnte C MISE OF DliATII in pltiin It-rniH. tluit it mjiy ^»- properly cluKMified. The "Speciiil Information" for per-
sons clyin^ nvviiy from home sliouhl be (^iven in every instnnce.
rZ-ri^''
i^^
^m»jiA
rr^>4#f5».
-f^^^
"T'T"
I
Wl
>li
y^ ; I
iM
WRiI£ PLAINLY WITH UNFADING INK — THIS IS A PERMANgf^X^ECORD __
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
\ nu/c Filed , LIa.a_/0:/UC^ 3lId
/.v^y^
lie^isti'red jYo,
\^A
0^..^^\J'>J^J^
Deputy Health Officer
N
DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco
Ccvtiticatc of Beath
PLACE OF DEATH: — County of^JOyTL 0 .\^CL'>^c.^.^c^City of vJo^^ru OAxxz-y^c^A^^^i.^^^
o. I 0 5 ViD JLXATvxxA^/dj St»; \ Dist.; bctcLe>OLAj-CAax.oWlJk and V^-^nJU^
(IF DEATH OCCURS AW*V TROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' ' \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND N U M B E FK >
FULL NAME bJo (lb C^v.u<)L^xi cIxX/^axj.
)
si;\
i)\ri: m iiirtii
A '.I-;
PERSONAL AND STATISTICAL PARTICULARS
^ 1 )!.< )R
i.
rVA^C^
^M.nith
\
SI\<-.lj:. MARK 11 ! >
WII)(>\VKI> OR I)!\ I \\-.< i:i)
'Write in social (h -iv iialinii)
3
(Diiv)
1/ ,,,'/'.
(Vt-ar)
MEDICAL CERTIFICATE OF DEATH
DATi-; ()i~ i)i;ath
^ I
'Driv)
I go \
(Year)
X\
I'.ikrniM, xt").;
(Statf <>i (/i )U 111 1 V
N'AMl- ni
l-ATHl-.K
i!iKrni'i,A<'H
'»|' I APIIl^R
-,! ,'. ..v c .Miitrv
M \il)i:\ NAM 1
'>! .m(»thi;r
lURriin.ACH
<»l- MOTIIICR
( stair .)!â– ConiUrv*
% 1
r 1 1
1 lli:ki-;i',\' C!;RTI1-\-, That r alUn.liMl <l(>rcaso(l from
LLo^ lb iqoH (.. vLmwO, ^b ic,o H
that I last saw li -'- .>. alivf on LA.A<\X3l Q; 5 T,p "-^
and tliat ik-alli ocfunxMl, on tin- <la1r stated al>i)vt>, at D
vL M Tlu- CAI SP: Ol" Dl-ATII was as follows:
^<^^"\'\J
or RAT ION )'ev;;-.s- 3 Months ^^ /^^nv
coNTkir.rToRV
I lours
orcri'ATioN
)V',/
O v'...//... 0,1
1)1 'RAT ION );•<?;-,? Months
(Signed^ M-- uajui/w
0.b i(,oS f \ddiv^^) IbKo
/>^/i
'S'
Special Information f'it!\ tur ho
or Recent Residents, diid persons dvini d>vdy Iron home.
I lours
M.D.
fill-: AHox'}.: sTA'n-:i> pKRsovAi. tar rim.ARs \ri- i'r; ]■■)•(» \\\\-
lil'lST MI.' MVKN< »\\lj;i)(- K AM) IIl'I.M'F
Former or
Isiidl Residence
Wfien was disease contracted,
If not at place of deatfi ?
How lonq at
Place of Dcdtfi ?
. Davs
nrijil
"\
\ Mi.-
^
(OS ViDjLTv/YvxxxAot
â– 'â– â– I^IUIJ
IT.Al"]-: ()I- lURIAI, OR r];m.)\-ai,
,0
''K^vJ^ V' <^CK,
V,A.*— VV^
r N I ) ;
fA(M!
DATr: .,!' IJiKtAl. M! Ri;M( i\ Al,
^''^' Kvery item of informntion should \m ciirolfuny supplied. AfiF. sho-.ild be stated F'.XACTLY. PHYSICIANS should
state CAUSE OF DEATH in plnin terms, thnt it mjiy he properly clussificd. The "Special Inlormation" for per-
sons dyinJi away from home «shoidd be 6'^ en in every instance.
I 'I â– â– â– '
i:;
!â–
i.j:
ilJi
I 4j
^1•■;Y
f?l
WRITE PLAINLY WITH UNFAmWG INK — THIS IS A PERMANENT RECORD
I{,.;it(! ..f !h;ilt!i I-' No. I. "C-? IS. *;'.: !!X:l'r..
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Jico'/.s/crcfl A^o,
d^^vv^os^ ^dOL-a-v< Deputy Health Officer
DEPARTMENT OF PUBLIC nEALTH=City and County of San Francisco
Ccvtificate of Bcatb
( 11. 5. t?tnn^ai-C> )
PLACE OF DEATH: — County ofC'CL^^u OAXX/TVCXv^cc City of^'CL^r^ vJ.^vCX/>^'C<w^-co
No. 0 1 1 '^ v]j/UXoa/-yX.OL'>A.' St.; '1 Dist.; bet. iXJoj and 5 AJv
(IF OEATH OCCURS AWAY FROM USUAL RESIDENCE give: facts called for under special INFORMATION" '\
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
Si; \
PERSONAL AND STATISTICAL PARTICULARS
1> \'i 1' I '1 ;;; i: 1
CXAa^
A^oJL«
MEDICAL CERTIFICATE OF DEATH
i)\ii-; < n- i)i;.\ I H
2.S
CMMiitli^
(Pavl
J0(^ '•â–
\' .11 '
AC.IC
an
M..!!"!)! I
!
H
lb
SIVt.l.l-. MARK II' I)
Ullti tWJ-.It < >K I)i\« »Kv|';i>
MIK I'll ri. \^' 1-:
' S1;lti r>I ( '..lint I \
!)l
<X^'V/UL<i.
V\MI'. (»!•
lATllliR
i:iKi'iii'i,.\v'i';
<>i" i.\riii-;k
'. S;:i!.' ,,t t",)iiiitl \-
^^ V I i ii; \ x \m )•;
<'i M')'nii.;!<
r\y\j .
I Ill-;i^i;i;\' Ci;i<'ni"\-, Thai I alU-ink-il (Utl-.islmI In. Ill
thai 1 \:\<\ ^.\\\ li • ' ali\roii \>AwV\.X^ '.i,H n^o ;
ati(l that (iralh i x'ciii iid, (M1 thi- «l;itr statvl ahM\-(.\ at l-OL)
M. '\'\\c OlSh; Ol'' I)!-:\'ni was as follows:
^1 rA^^C'-^iiyCv^Nw/^^wCAw^^^}
I'.lKTliri.ACl",
op MolHI-'.K
' Stall Ml t'duiit I % *
< H'l 1 r \ i' h i.\
1)1 k \'ri( »\ );,/o'
c( )\ !"k nil Ti )i
I fours
.... Months 10 navs ...■„,.,
.â– /A"////s-
/hn
SlGNEI
Uxc<
\
X5" I()riM (
g ^O |,)r,M ( \,l.lrrss)
diAL Information "nH
\,i.iivss) S N ri-a4.c'>\, Ot
I hull s
M.D.
SPECIAL Information "nH lorllospilHls. Inslidilions. Irdnsienh,
or Rpirnl Kcsidcnls, .md persons dviii'i .iw.iy fro:ii homf.
f (inner or
Usuiil Residence
When w.'s riiseiise ronlriii ted,
If nnt .it pl<j( T o[ dedtli ?
Mom lonii A
Pldcr ol ne.it h ?
Ddvs
riii-: \i'.()\-i-: sr \ri:i) i'»':ks<)\.\i, ivxurit ri. \us \ki; tki !•; Tc > rii p;
Hi'.sroi' \)A_K Ni (wi.i'ix'. !•; \\i) iu:i,ii:i-
( Inf. â– â– ni:mt
'^
a
\'i,hr^^ 5^ 11 ^^ vu .h^cL/>v-Y-vxx'>v d:^
3.
ri.ACI". (>1- lU K 1 \1, itk k I.Mi i\' Al,
1) \ 11:..! r,i 1.; I \l ..! K I'Mi )\' \I,
a
r.NDl'KrAKllK
o^ 11 L 1 90 S
N. B. Hvery Item otf iriformsition Khould be ciirov'iilly hii{»i>I««^«'« ^•Jfi Hhtnild he Ktnted FiXACTLY. PHYS!CI\.NS Hhoiild
stHte CAUSE or DfiATH in plain tt-rnis, tlint it rrmy bo properly cfuHNifieil. The "Spcciiil Inlt'orniiition" for per-
sons dyin^ nwny from homu should be dtiven in every instnnce.
I
« I,
1 :
i I
\'
â– t
S
1 '
ilif
\\
If
i
i
\
m
WR1X£UBJLAJJ>JLY WITH UNFADlMgLiJiK — THIS IS A PERMANENT RECORD
!;,>,•,! ..f Iliriltli 1" No. i^ ■r*'*'^«'^^C*: HS:I> Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
tj 'Xio
If)OH
Eegisfercfl J\^().
X.f^f^tS
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of Bcatb
[ li\, J?. Stan^arO ;
^
<Xyy\j 0 Axxo^»^/Ca..^^o<>
I^.
PLACE OF DEATH: — County ofC'^Xo^ 0 Axx.^v^o^-^x:o City ofvJ'
A / ir DfATH OCCURsAAWftY F R O IvA USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION â– \
y V IF DEATH OCCJ^JRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
'Ch.Vwtu db (Kiv^'ta.1 SU Dist.;bet
and
FULL NAME
•Jt'
IX/^Ty'VC^ro
ZJ^^
SHX
H \ 1! I ' l;iK 1 II
PERSONAL AND STATISTICAL PARTICULARS
A'^aIjj
ixWfc
^!.)ntIli
(D.ivi
,\\i'
\ (Ml
\' . 1-.
\o'h
)..l.
10
si NT, l.I' M \K\<\ I l»
\\ ID" •Ul.D ( »K l)!V(>hHl-:i)
Utile in Mifial (It'^ij.'natiDii)
I'.IK TH n. \i' 1"
I Sl;it( <ir (,'i 111 nt \\ '
NAM J (»1-
I- \'i'iii;k
lUKlll PI. AT}-:
i>i' I AT in-: R
â– ~1 iti 111 C'dlUlt I \
M \1 KIN NAM I',
til- M()Tm-;K
lURTMPLACK
<)i" ^t()T^^:R
(SUitc nv Coviiitvy
MEDICAL CERTIFICATE OF DEATH
I) \'rK ol- IM'.ATII r\
m-:ui:i!V ci;rtii"v. Thai i aitiMidf.i .!c.xmv;i.,i r,,„ii
LA-OLO 11 i«)oH to LA^CvCv 'X'h
11 I(;oH to \J^L.\,Cy 'k'^ U,()^
lliat I la^t 4aw IH- ' -•> ali\c'oii VA^^a^ X"^ k^o ".
ami lliat (k'atli ocourrcil, on the (latr ^tatnl aho\f, at : •
M. Thr CAlSlv ()!• I)i;.\'ril wa^ as lollops:
,\-<j..
DlkATloN )'rars M on tin Pax
CONTR [I',r'r< »RV u\0MA^^-^O-<3^^^*^'<i. \J<
i-cyW^O-^
J loin s
DlRA'PfON
( Signed )
(w
ViUirs
j«:%
a' I
/'/I .
OCCri'ATlON
.(^
\
<i^«
Sion'i (A.l.ltvKs)
ve.
/ lours
M.D.
^Aiifi.
Special Information "niy for iitV^pitdis, insiifufions, Transients,
or RciTnt Residents, and persons d\in) avsay (rom home.
Former or 'I'-iQ t-fV "^4 Hov» lonq at .
L'sual Residence ^ ^ I ^ O 1>\; ~"n P!d« e of Deatfi ? to
. Davs
M.'uth>
/\n.
rm-: auovi<: st \Tj:n pkrsonai, rAKTirri,ARs aric iRri-: i( » rn i-:
lu'sT (>i- ^L^• KN<)\\'Li"i><'. !•; and i!i:m}:f
I Iiifiniiuuil
Q. X etx...^
Wfien was disease rontrarted,
If not at plare of deatfi ?
ri,ACi': oi' lURiAi, OR ri;m(>\ai, I i»\i!_^.; '. r \i .,t ri;m(>\ai,
Ni»i.RrAKi:R v'VJL'OLu, ^
T90H
r
.'/CuCycv
N. B. Kvery item olt inforniiition should be cnrefully supplied. Mir. si >iild ho stjitcil f;\ AG TLY. PHYSICIAINS should
HtJitc CAlISr. or DI:.\TI! in plain terms, that it may be properly chiKsili'ied. The "Special Information" for p«p-
sons dyinjj nway from home should be feiven in every instance.
â– h
i
â– M
|i|
I N.
5.<l
iij" :i
' I
't *
hi
i'i
.1;!
■^S«»
^a%\i
m^
^P;
WRITE PLAINLY WITH UNFAJBIIMG INK — THIS IS A PERMANENT RECORD
I'.cvii.l iif IlinUh -!â– â– No. K t-
• Ii>S:l' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dale Filed , LLu^c^Q/v^^^^aX X\q
l\)()\
lle^ltitcred JVo,
\.'i^'\
DEPARTMENT OFTPUBLIC HEALTH=City and County of San Francisco
Certificate of ©eatb
11. S. StanDarC^ )
PLACE OF DEATH: — County of C'<Wu 0 AXtywcA^co City of vJ/CLav 0 )\Jxr>nj^tA,^^<:,
1^ *'
D(y<L
St.;
Dist.; bet.
"and"
/ IF DEATH OCCUwfe AWAY FROjM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION' \
V IF DEATH OCqtRRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
y^
c
PERSONAL AND STATISTICAL PARTICULARS
1 : .\
> \ 1 i: 1 'i
lUcJL
COI,' iR
U'vda
ii
/"^(o?
.\!nlllll'
\( .!â– :
3>q
y. ,.•••
n.iv
M.'ti'lf
/hi 1 ^
W IDt t\\ l-lt ok I)1V< >Rri.l)
'U'ritciii suiial (k'^U'iiatioii)
luK rm'i,.\ri-:
olVvoixL
i'.\ rin:R
oi" JAIIIl'.K
M\Ii)i;N N.\MK
<)!• .MOTHF.K
ItlUllll'I, \CV,
<»F MOTHHK
(Statf (ir c'oiiiitrv
aXx^o
MEDICAL CERTIFICATE OF DEATH
iNIontlP K il);iv) (Vi-:ii)
I iIi;R i;i',\' C"i:i<TII-\'. That I attcn.U-.l (lt(\;«scMl from
vAa^UDl ^"^ 190H i<. LXaa/Q 'X^ Kp H
that I last ^aw h ^^Vv ahvf on vA^V.a^CX 'X'h Tip 'i
and tliat <kath occurred, on the ilatt,- ^tatc(l ahov*.-, at iHo
J .M. The- CAISh; ()!â– I)l':.\'ni wa^ as follows
DT RATION )'cars
CONTRir.rTORV
Mouths
Pays
IIouis
^ ?
US /oJruUv'
^Lcu^
(Signed^ 0 . VJI. 00 /cuvt M.D.
I )!' RATION ,,v^)V<L/-.v
55.
I
^b i(,oH rx.Mrc'^O
V(!<^%(Vvl.^t
SPEC'IAL Information ""'^ 'ur Hospitals. InsHhitions, Transients,
or Recent Residents, and persons dvin:) a^'iy fro.n home.
Ji.
O^oJt^''^ '-
HoH ionq at
I y,;n^ I
,1/,. '.-'//
/',,â–
'in I'. MJDVK SI" A '!"}•; 1> S'KRSONAl, I'AR rUTI.ARS ARi; I'Rri:
i!i:sT <>i' Mv Kxowi.i: I )(■.}•; \\t) ni:i,n:i"
•<) fin-
'Info; inant
^
X-tr^^XX^ vjX^xtti
I N.l.lrr
Usual Residence H 'XH Vj O^ojt-^t ^^ji pi,ife of Vatti ? 5
When was disease contracted,
If not at place of death ?
Days
riwXCH Ol- lURI.XI, OR RHMoNAI, I !)\1K.>! K<ki.\i. ,,i ki:M()\-AI,
d
:i)i:rtaki:r J^uJLiu ^^ (TO
M. B. F.very item of informntion should he carofull.v supplied. A(]K should be stated RXACTLY. PHYSICIANS should
state CAUSE OF DEATH in pinin terms, thnt it may be properly classified. The "Special Informnlion" for par-
sons dyin^ away from home should be jilven in every instance.
I
,.|!
\'>:
â– I
1 »
I'l
i I
<..
:!^
< t
<«
»
i
^SifiJ^
-â– ,*•'â–
"""P^
f
i
N
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
/><//
r /'V/^'^/, \J^A./c4W-At Ovlo
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
IfUJ'i
Bo(^isf('i'(>(l .jYo.
I OOP:
^
\
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
PLACE OF DEATH: — County
Certificate of Beatb
of vJ/tXo^j 0 A.Ou>x<^UL<^o City of 0<X/y\j 0 AxX/TvCA^y<^t
%
No. lb n C3-<^ttx.'vi St.; 0 Dist.; bet. MD (OJ(lX>' and (Lcytprv
/ ir DEATH OCC'JRS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION' \
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J^
FULL NAME
Wti
si:\
DA'l 1 â– '! 1!1K 111
\' . I'.
PERSONAL AND STATISTICAL PARTICULARS
r( ii,< )k"
\\xLi
'I):iv)
/L ;
MEDICAL CERTIFICATE OF DEATH
DA Ti-: ( u 1)i;a rn
(Day)
1
a
a
â– ^I\< .I,!" M \ i; In I II)
i;ii-.' i iiri. \>' r
'State or C'nuitl %â–
N'AMl-. ni
!• \ 11! i:k
I'.iKTiiri, A't:
" I \riii'K
~-' ' ' ' ' ,; 111 • >.
M \ ii>i-:N N ami:
•M MoTlll'.K
iiikTii ri. xri'.
Ml- Morm-.K
fSt.'ltr or Couiilivi
' H * cr \ 'I i< IN
/■,. ■,,•',,'•
(M'.iith"
I Ili:ki:r.\' CIvRTII'V, Tlml I Mttm.kMl dcci'asod {vmu
" I (/J U> ~~~ Ii/D
lliat I last saw h alive on ]^)0
and (hat death <KH-iirred, nn thr datt' slated ahnve, at
M. The CMS!', oi" hi; AT I! was as follows:
DIRA'I'ION ]\<irs J/<>//7/fs /)u\s I/nnrs
CONTRilUTom'
d
OJ\jOlXxJ\j^^^ X ' I
A
y<^.^\
<OCrVA.o.->
n
\\,\
A^CrV i-^tr^^
1)1 k.\'ri()N )V./rv Mn}itlis Pays //oins
I SIGNED ) L<)•\Xr^^JL^u J.vlj.Lb (^ M.D.
A.hin ss) Wurv>aA>c> V.
Special Information "ni^ t'>r ti'ispiinis. ii^iiiuiiort'srrr.insipnis,
^UL
or Rercnt Rfsi'lpnts diid persons dyinj HWdv Irnm home.
5. y-"th X I-
Former or
IsudI Rcsidrnre
Whfn Has diseasp ronfrarfed,
It not a! plan of drafh .'
HoH loni| al
I'la. f ol llfath ?
Davs
THl'. MtOVl': ST \Ti:i) rKKsMN \ !, T \ K f U" f I. \ K ^ \ K i: IK ' l' Ti » Til 1-;
m:sT ()|- MV KN' >\\ l.l.lx .K WD III" 1, 1 1 : !•
' Ii' r. :â– iii.-int
\d.ll(
lioll d^^udlAjA, c)l
ri.Ari-: <»iv.r'! rial mk i:i;M't\\i,
I l..\V I'.
D \! 1
loo't
IN. B. livery item of iiit'oriniition shotilil bv- csirct'tilly supplied. AdH Khmlcl be Htiite.l I.V ACTI.Y. I»IIVSICI\NS should
Ktntc CAIISI: Ol- ni-,\TH in i)ljiln terms, thsit it m:i> be properly clussilficd. The "Spe-iiil Inforiiiiilion" for per-
sona flyinji nwny from honic shotihl be given in every instnnce.
IM
>
mi
M
\ ;
i!
< I
i
â– I 'I
l<!
!|
I
il:
\' .'. ■»
.'*vy
m :
,-y
"ffr
^1
I*
I4i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANETNT RFCORD
I'...:i!.l •.r Il'.;i!th I'No :-. ■0-*7'=^-:..:-4: !!5;:r Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
l)((fe /-V/r^/, IXcvXI/C^aI' llo
itn)^
Ecgislci'cd J\^o,
22Q
cK^<r^^A/^^
Deputy Health Officer
DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco
Gcvtiticate of IDcath
( "U. S. 5t^n^al•^ )
PLACE OF DEATH: — County of O^lA^ OAXUvxCv^lcc City of 0<V>^ 0 AxX/->-vt<.A..
J QJ
C-L
No.
,fc
\XA
OaLK
(I r or ATH OCCU RS
IF DEATH OCCU
.KX.<X,h
St.;
Dist.; bet.-
and
AWAJv FROM USUAL R ES I DENCE GIVE facts called for under "special inforvat
RRED IN A hospital OR INSTITUTION GIVE I
(^
TS CALLED FOR UNDER "SPECIAL I N FO R V AT I O N ' ' \
TS name INSTEAD 0Â¥ STREET AND NUMBER. J
FULL NAME J^^
PERSONAL AND STATISTICAL PARTICULARS
COI.OR \
f
I
<rY\ywcr\j
L^(a>jL^
DA ri-; ' u i;iK I'll
\ ' . 1 :
l^\
l:i \
To
)..!
^IM.I.J-. M \ KK 11 :>
WIDOWKI) (»K DP
mk iiin, \ri-.
'Stjttc or CuiiiUiv
\ Ml ( )!
1 \ 111 l.K
I)
i)
MEDICAL CERTIFICATE OF DEATH
DA Tlv ol- DlvA Til r\
iMoiilli) /T (Day) (V.-ar)
I II!-:ki:i;V i.!;i<'ril"\-, TIimI I .ilUtPka .Iccrase,! In. Ill
\X\^<x y^. Dpi i<,
that I last saw li -V . > \ aliw on
3.H ic,oH
aiiiltliat (U'atli occii rrcil, on tlu- dati- ^(atnl above, at 0
\S .\[. Tlir CArSI'] Ol- I)i;.\rii ua- as foII<.s\<:
liiKriii'i. \i K
MAIDItN N\Mi:
<»1- MOT I UK
lUK TlllM.At 1-;
Ol- MuriiKK
''-la?'- or (â–
' ' ' ! ! ^ I 1
AV
'^lili'if in '<<nr I'l ,t n, : • i-it ^\
D'RATION )V<?;-.9 Mouths \ Daya IIouk
L" o N T R M ; I â– T <) K \' L vWcA.<XWr>v A ^-OurLv^X % v^
I )l RATION )'i\irs Months 10 /J^/i-.v //r>i,r^
NED ' UJ. Vj vJlAA.Ul>crv\ M.D.
^ SIGI
A^ DKi'l
'M.*^ t
Special Information "nu for iiospiidis. insijiutions fmnsifnts.
or Re(ent Residcntv. dii'J persons dyiiij drt<)v fro'ii homp.
former or
Usuiil Rcsidenf
Plnre ol Oedfh ?
II
Ddvs
Hi: A!{o\I-, S'l" \l I D I't- !<«.. i\ \l, !■\|,'. Ill- i ! \ !<^ \ |< ;. tk I
'*5'>l'': M. I X' t\\],i:Di.I>: AND iiri.Ill-
When was disease confrac ted,
If nol af plare of d?dffi ?
■< » 11! )•:
' Inf..- !i, lilt
WTVAV LchLLo^'
^\.i,i-. ^,
I'l. \i;j;: ( ir imr i ai. < ^\- i' i ^T' i'/ v j.
fc
(axj Uuna^
0 (\ f ot
f NDi.k'r \K i;k v-VJ. V v^
^ - I90H
0
'^' **• livery item ui inltoriniitloM fihoiihl hv carct'iifly suppilt.tl. \(\V. s'lf.iild be staled FiX ACTLY. PHYSICIANS kHouIcI
stHte CM'Si: of: DI: a TM in phiin terms, thjit it m:i> l>j prt.pcrly cloHsifietl. The "Spcciul liiiormriliin" for p«r-
«on« (lyinji »wa>' from hf»:nj should he feiven in every instnnce.
Ti
)!
n
i
"Pi
}ih\
. t
li
II
fcii 'iitiii'
*^*^.
I
»l
#i
I
I
!;. .,,;,! .,f II. :;Uli 1' N
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Ii\:r c
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/)a/r F/Irff, U^UwaA./^t. llo J^^O^
IiOi^i^fci'cd ^A^o.
J 236 1
cLxr^cA,^^^
Deputy Health Officer
DEPARTMENT OFPUBLIC HEALTH=-City and County of San Francisco
Gcvtificatc of iDcath
( U. 'Z\ 5tan^al•^ )
PLACE OF DEATH: — County of O/dAV OAXX^'^'CvxiCt City of C)/(X->\; 0 AXX-^X/Ca.a.c.-o
f*«.
d.fc
o^K
(IF Ot ATM OCCURS A\
IF DEATH OCCU RR
.aX<x1)
su
Dist.; bet.-
and
wa|v frow usual RESI DE NCE GiVF facts called for under
ED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF S
(^
FULL NAME
yU^
.•^i;\
1' \ 1 1, ' 'I i;ii< 111
PERSONAL AND STATISTICAL PARTICULARS
C(»I,((K
"special INFORMATION' '\
STREET AND NUMBER. /
T
la
XA.^t
,l^\
M.Mith*
\ ' . 1 â– :
^>
iO
1 I):t\-
\hnith-
Ihr
--IN'.l.I-". M\K1<II-1)
\\IIH)\\ l-l) OK |)l\( iRi).;!)
' Writ' : , : !t -i-^' n;it i( iii )
luu rniM.Ai'j":
' ^t;itc iir CoMiili VI
^ Xj^-\.\
N \M !• oi
1- \ III l-.K
lURTIII'I. \i'!-:
'>'â– I \rm:k
'Still 'â– i il (.â– ( illDt ! \-
MAIDl'lN \\M1
"!â– MOTIIIK
P.IKlll IM.AC
'»! M or III-;
IS!;:t. -,| (â– , .,
MEDICAL CERTIFICATE OF DEATH
I) All-; oi- DivA'iii r\
iMonth) K (I):iv>
I III'KlvHV Ci'KTil-V, Tlial I :itlL-ii.lr>l .Iccrascd fmiii
\^-' upi to CU.>U>. M
(V.-ar)
IqoH
0 q
aniltli.il tlfatli occurred, o;i tin- datr ^tad-d above, at 0
tliat I last saw li -\-- '^^ alixi-oii
VJ .M. Tlic CMS!': OI' I)i:\'IMI was as follow^:
^
CONTR M;rT()k\' L vUjA.<xAAXrvA. irWUru^^-v-
or RAT ION );v/s- Months 10 /W.v /A»///-.s-
( Signed) Uj. \j . U[\a.Ia.c^\ m.d.
Add rc'^>^ ) 0 1) XuJkJ14 fe iV^^) .1.'
OvS i(,o*l (A
Special Information "nly for Hospitdls, Instiliilions, Transients,
or Recent Residents and persons dyin;| dway fro:ii liomc.
Former or
Usual Residence
When was disease confrarted,
If not at plareof deatti?
r\JX)
LoJC
How lonq at , ,
Piare of Deatti ? 11.. Days
'nn: amovi-: st.\ ri:i) pkuson \i, i-ak ricn.ARs \\< i; iKri': to th i-
lUvST Ol- MV KNOW I.l'DC I-; .WD IlI-.M!",!-"
niifiiMjirmt
f V.l.l
wrmmmtm^
v\,\(^(n luRi.M, OK m;Mo\Ai, I dxtj;.,.'- in ki.\i. ui ri;mo\ai.
VlrUxLOAxrvx 3^
'^- ^' Every Item of information should b ciircV'ully Hupplieil. AGR Hhould be stated KiXACTLY. PHYSICIAT^S nhould
state CAlISf: OF DflATH in plain terms, that it may be properly claHHified. The "Special Inltormation'* for per-
sons dyin^ away from home shotill be (iiven in every instance.
< r
'•I'
i
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m
'i : •»
, I
. » I
I
fit'
ii-.jy
'W^i£S
uk3Rn4^
PHIflllli
ili
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PFRMANr
NT atrnr\or\
!«.,.•,! .,|- I!. ,,'ih l- \-,,
t-"^""!-
IlXiI" c,
VHu Deputy Health Officer
_____ _^^^R â– ''O B^CK OF CERTIFICATE FOR INSTRUCTIONS
/.'^^n Jiro/^fcrrd A'^o. 1227
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of IDeatb
( U. S. Staii?ar? )
PLACE OF DEATH:
County of Vj/a^^' JA,ay>xeA.A.^i^ City of 0/CL/>v 0 A^O^-n^XM^^C^
ll
N«.UL>vt\.<x)b U"^ve.\,q'C/vvCu (lb(V<ll\AjtoSt;
Dist.;bet.
and
/ ir DEATH OCCUflJk AWAY r^OM USuIl R E S I D E N C E G ! V f FACTS CALLTD FOR UNDER 'SPECIAL INFORMATION' \
V IF DEATH OCclj^RRED IN |A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STR E eJ AN D N U M B E R )
FULL NAME OjUrXa
loJ
x<X/»v \J )v.^zLt'v
Lt\)
PERSONAL AND STATISTICAL PARTICULARS
QfUcoL
I' '. .1 ' 'I l;iKrii
\' â– I
Qli^
M.'iiliii /T
rli^
%\
MEDICAL CERTIFICATE OF DEATH
(M..iitlil I iDny)
I m;RI-:ilV CI:rTII-V. That I atlcn.lc-.I ^Ic-ccascd from
(Year)
\l
n.t
'^ i" ' . i.i:, M\KKii;i)
\y\\u >\\i.;i) OK divord:!)
â– Miiti. Ill)
VV'it. in
lUK rui'I. \('K
' Slatr or Cdiinti \
I V ill l,k
I'.IKTHI'I, AfF
<>i- I \ i"ni-:R
iStat. ,,i I . ,,,,,1 , ,.
Mxn)i:\ XAMi:
ink ruiM, \( ).;
<»!• Mori IKK
'*-!.!, , ,1 I'. ,11 lit! \
"â– '"li \ IK >X /
^0-trVA,>^*V
that I last saw li
1 90 l(»
— ali\c (111
ic)0'
190
and Ihat diatb « .ctii rrod, on tlic daU- statoil ahovo, at -
pp^I. The CArSl<; ()].' DI-ATIl was as follows:
1)1 'RAT ION }-tU7rs
tONTRIIU'roRV
'Tt^CV/V'
Moulin
Days
I Jo 11}
nays
«n
r^'
!^f^
-v^
IXu.
//ours
M.D.
1)1 RAT ION ^ }\'ars ^ Jfnnt//
(S^IGNED^ U3\>Cr>\J2A' 0
Special Information only for Hospitals, InstitiHions, Trdnslents
H InoH
C^. <A \ I()0*
STalTnif
cV'CU
or Recent Residents, dnd persons ddng dWdv fron fiome.
1 !V,,'- (,, I,.',////.
/'.
UAxXX^rvo
How lonq .it
Plareof Deatti?
When was disease (ontrarted.
If not at plareof deatli?
Days
U^/CucL^ UunrLu LcxX I wU-vc\_ Xl» igoH
Infonuani
LU. Uj. UaNjeAjL<rv^
r\.l(lr.-.s
I'^b c3 A^v.fcLjt>u
it
rNin:RTAKF,K \l \. O Axxa^ ^<C ^<i
via ^
. B. Kvery item of informiition shoiiltl !>.- corefully supplied. AGE s!iovild be stated EXACTLY. PHYSICIANS should
state CAUSE OP DEATH in plnin terms, tliiit it may be properly clossilfied. The "S,)ecinl Inform»tion" for per-
sons dyinfc away from home should be 6«ven in every instnnce.
!1
. â– n
..V' •'■;
^^
u
V
i
A
'9'
hi
1
\
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/>///r /v7r^/, LicvQA^uA^
0.1:)
/fn)\
X^A^v^ JoLv-H- Deputy Health Officer
Boi^isfrrcfl jYo.
1228
I
DEPARTMENT Ot PUBLIC HEALTH-City and County of San Francisco
Certificate of IDeath
11. 5. 5tnMC>arC>
n
1 1
1/
om
^
PLACE OF DEATH; — County ofO/CU^rv J A_XX/^\/CA^t/City of 0/CX/^y^ J A^CLz-wx^ca^cx)
(T. . V I rw. . ^. f . . /tin (y<.W:CLl St.; Dist.; bet.
N<;. ^KXu. ^'^\^<yv<yy'
and
/ ir DEATH OCCURS jCwAY FROM 0 S U A L RESIDENCE GIVE FACTS CALLFD roR UNDER "SPECIAL INFORMATION" \
V IF DEATH OCCUI^JREO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
• \
> '\ . I. * '1 ill Kill
PERSONAL AND STATISTICA
C< iI,mK
FULL NAME VOrnxU
L PARTICULARS ^
\J
XjA^\Xji
M"nili>
H
/1(^i
u iiM)\y)':i) I >i< i>i\ < tk(i-:i)
Uritcin mwial <lr«.ii/ii;itioii
lUiv ill iM. \.-!;
fSliiti' nr I'oiinli \ )
^ â– < Mr: ni-
I \rin,k
I'.IK IHPI, \t}-
HF 1 AT III-: R
M \ii>i:n n \mj.
<'!• .m<)Tiii;k
'U
IVtEDICAL CERTIFICATE OF DEATH
DA Ti-: oi I)i:a I'll /O
I m':KI-;ilV n:RTll'V, 'rimt I ntlen.lrd .UHva^rd from
tli.il I last saw li .L ,», ;ilivc- on
(Vf:ir)
\()0 ^
190 'i
and (hat .K-alli ofriinx-d, on tlic date stated above, at ^- 15
^^ AI. The C\\rSl<; Ol' |)i:.\Tfl x^as as follows
.^<^
t^^^^r>A.-(x>VM J^w[m.^^^iaaJL<kui^.
^./y\/y\}
DIRAl'ION )\-cns
CO.NTKIl'd ToKV
J/(>>////S
Days
//ours
I U- RAT [OX ^''A!' (>\ â– ^^''""^'
(SIGNED) 0. VjV. ()l9oc>ob
/^avs
//oins
niRi-iii'i, \ci-:
<>i M<>Tm:R
(Sh)' or r<)inilt\ I
• '' '"i I'A ridx
A'' i/c'i/ /;/ Sail /'i (I III isi'i) \ )V.,';>
LiV-UQ XS^ IQOH rXddresoLClu^
Special Information only loi^iiospitais, insiitutions' rnmsienis,
M.D.
or Rcrcnl Rfsidt'nfs, dnd persons dvini) awdv froni home
Miiiith'
1\!\
Tin-: \ii<»\i.: sr \ ii:i> im-rsonai, i-xrikti. ars ar i-: TKn-; To \'\\ v.
I'-l-.M' OI MV K No\V|,i:i)C, H AND in;i, 1 1, 1-'
n..fM-,„:„,t \Jje^ vT X/ojbo
Former or \n^\\
Usual Residence I I b \J XVvm
When was disease lonfrarted, ^
If not at plare of death ?
A 4- now lonq ar
^'^ Plareof ')iath? n
. Days
Ljtui ^ v^ (jb CH^v Jbxi
'"'•^'''- A^'« '''J<'-^'' "1^ KI'.MoXAI, DVTl^,! \\vn\\\. or R]-:Mo\AI,
U^^i^ ' (^''-^ ^1 190S
r\Di:RTAKi;K U <xJ!j./>a^ M iXoJv^s^^vuo ^<^
^' ^' fivery item of itiV'ormntion shoiihl be ciirufiilly su|>plio«l. \V%V, should he stntcd F.XACTLY. PHYSICIAINS should
Htnte CAUSE OP DEATH in pinin teriiiM. thnt il mii> Ik- properly cliiMsilfieii. The "Sjieciol Information** for p«r-
Ron« dyinjl nway from home Khould he (^iven in u\ur.\ instnncc.
}f
I
m
i
If
1:
4
!'i
ri« :
â– I
J
I ' '
i
^nm.
4
*A4
l!
I
I
I
1
4
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
: Mi.l ..f II. :.'th I- V.
-"■•; HX: !• (â–
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Ihdr Filed, LU/^^^a^^^ :Xlo l'^0\
lle^istvicd JVo,
1229
Aw^Ci
Dep*
y„t ^ , . » •, 1.^
rOfTT
DEPARTMENT OF PUBLIC HEALTK-City and County of San Francisco
No
Ccvtificate of E)catb
( tl. i5. 5tati^arC> )
PLACE OF DEATH: — County of dcLA^ vJXX)u-rx^o<LCc City ofC),
^^V St.;
Dist.; bet»-
and
^ ( ' ,r nr'lTH^nrftM»*J*'*r.' '^°"' USUAL R F: 55 I D E N C E G I VE tacts called roR UNDtR -specal .NFORVAT.ON' \
\J V IF DfATH OC(JlJHRCO IN A HOSPITAL OR INSTITUTIOM GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
)
FULL NAME
I
xolaJuu \JL<x
^i: \
PERSONAL AND STATISTICAL PARTICULARS
1
./
r.IKTU
\
\' .!â– :
|(i..iii!ii y
.1
n
\
1
''»\ar)
MEDICAL CERTIFICATE OF DEATH
i> A I1-: < »i- i)i:.\rn /O
(M'.iitht A (Day)
I 1M{RIJ5V i;i:RTII-V. TIi;iI I atlL-n.k'.l .Itvc-asc.l from
- I,, _
(Year)
luO
I
^iN<. i.i:. MAKi<ii:i»
UII»« >\Vi;i) Ok I)!\«)Ki }.;i)
\''': .'■!i ^■.. • ■• 1. i$ri)ation)
MIRTH I'l.ACK
â– ^ii'i "V '"'iiijitrv
\
lliat I last saw li ." alive oii '
■in«! Iliat (Kalh (uciirred, on tlu- dale staU'<l ahovo at
â– l(;0
I(;0
V \ M 1 ( )!â–
! .TIll-.K
HiK'nii'i \> 1'
Ol- 1 AriM.K
'Sfiitc or (.•(-iiiiti v»
M \il»J'. \ \ \ M \:
HIR rillM.AC!-
<>!â– M<'i"iii-;k
(Stil'i. .1 I'l.iMitl \ I
^tryv>v
VAax/^*^
M. The- CAISK Ol- 1)1;a'1'II was as folL.ws:
QJa^^CtXiJ^ OL/>x.d. db-^^-v^.tr*v^J(-
1)1 RATION Years Months Days
Hours
U
\
^\,<xa)a^^
C(».\"TRIi;rT<»RV
) \ars
Monf/is
Pays
1)1 RATION
(SIGNED ) \j^\Jn\JjM 0.^3.1)0. dUliUxy%.x/dL
//t^urs
M.D.
SPECrAL Information <>nU tor Hospildls, InslilulKo^s, rransimls
or Reicnl Rfsidenfs, dnd persons dvinfj dHdv from home.
Former or loO ^ / f 8 ^, How lonq af
I'sudI Residence ' vO b ^A-.-K; jX Place of Death ?
V. â– ////,
Wfien wa« disease confracfed,
I If nof at pla'^e of deatfi ?
Days
Tin; xHMvj.: sr\i-i:i) i'Kksonai. rAKTirrLARs aki: i-rm-
11' iiii;
'I"ri.:in;Mit
( \.l.!r.'ss
IM.ACJ; ni. lilRIAI, Ok Ki;.M.iV\|, DATI-..'- MnnAi. ui RllMoVAI,
dwAyVvCCr\yYAj
I m>i;rtakkk
M V\\^,/^>(w*-
'^^ ^* fivery item o? Information should be carefully supplied. AGR should be stnted KXACTLY. PHYSICIANS should
stiitc CAUSIZ Ol- DliATH in pliiin terms, that it msiy he properly classified. The "Special Informution" for per-
sons dyin^ away from home should be (>iven in every instance.
! •
' I
!^!
« I
[â– 'â– â–
\
1. 1
;K
if
f*
%
V
i4>
0
(
f
il
l!
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
â– ! ..f II. :i't!l 1' Vo.
/)((/(' Filed , LU/a>A/o<^
REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
aio
lf)0\
Registci'iul ,Xo.
\ ^m I
Deputy Health Officer
DEPARTJIENT OF PUBLIC HEALTH=City and County of San Francisco
Ccitificatc of S»catb
tl. 5. 5tnnc>arD
PLACE OF DEATH: — County of U/Cb^va-O/uo^-v-vCAA-ooCity of O OL^a, J y'i_0.^x^\^<i,o
No.
(I r DEATH OCCURS
I F D TATH OCCU
n
<i
St.; Id Dist.;bet.
S AWAY FROM USUAL R E S I D F. N C E G I V E facts CALLED FOR U rVl
RRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAb
and
ER SPEC
OF STREE
FULL NAME
lAL INFORMATION" \
T AND NUMBER. /
x>
\.\
\ . ! I -1 liik III
.\(.i-;
PERSONAL AND STATISTICAL PARTICULARS
r<ii,<>K \
MEDICAL CERTIFICATE OF DEATH
DAT]'; t>i iii: \iii
M :ith)
5S
^
10
1 I â– \
lA',////
. U4
IH
!">â– . .11 )
/)</
Month)
3vH
'l):iv)
(Year)
W
HIKTIIl'I,\i*H
' >>t:it<- ..r ( â– , ,,nii I \-
N \MI (tj
|'ATiii;k
lUK'IIMM. \. l--
01 i.\riii;R
'Stale- or I'oniiti v
M\!!ii;\ \\Ml
"I M<iriii.;K
iMRrnpi, All-;
<>}• \!(''I-HI"R
'fsi}.M)ati< n I
•x/ULcL
I III'RI'PA' ClvRTlI'V. That I attcti.kMl .leivased fn.m
190 t.. KjO
"^ T(;0
tll.'il I last <a\v ll
alivt' oil
ail. I that (liatli occurred, on tlic date- stated above, at
^ M. The e.\rSl{ 01.^ I)i;.\Tll was as follows
/CLA^ vJ AXWVCAA/tl^O
^JLJ^v
U
Ll) ii-^u^\Aj ot-US&^LL Xl.*^>a^ -c4x1jlv4-^vv>q
VMtvw v3A>*w0.v<jJfv»^
/"]
'^^a^aaaX
.^â– ^ yi
/T/Oj "^yLu^'vw
1)1 RAT ION }'airs Months /\u
CoNTRinCTORV
//on
IS
DCR.ATIOX
)'('<//-,s
Mo)iih>
i.t'i
'-^-^w>'am:5l/>
^^^
f SIGNED )U\XrvotA/ J. Mj.Uj.djJLoL
'^Aaax^ 0,5- j,,o^ f.\«1drfss) UA-^rv
\^cL M.D.
Special Information "niy lor iiospiidis, instifuyii^s, irdnsienis
or Rf( ent Residents, dnd persons dyini .mdy fro-n home.
^ 1/w,'/.- I ^ /,
'\'\\V. AHOVIC STX'll- I» I'KKnoN M, !• \ K T IC C I. A K S AKi: IKl ! !■> 111
in.sT ()!• .M\ KN( i\\ i,j;i)C. I-: \n;» ni-J.ii-i-"
Former or
L'sodI Residence
When was disease (onlrdrfed,
If nof ,)f pidte of death?
How long at
Piare of Death ?
Days
^A
.rsy-K
190
1M.ACI-: HI I'.IKIAI, MR RKM<.\ \l, I.ATl-.of ItrHiAr. o, R1:M(,vai.
r.\i)i:R lAKi.R (AD. J. 9-ovJ[v\j ^^ Co
N. 15.-
-rivery item of niforin<i(inn whouUI b.- c»ir«V'ully sii|>plic<l. AfJIi Hhrnild be fltnted RXACTLY. PMYSICI ANS Nhoultl
«tatc CAlJSr or Di;\TII in phiin termH. tbat it mjiy be properly clusKifietl. The "Special Informatiun'' ?or per-
sons (lyiri^ awny from home should be jjiven in ^K^ry instance.
.!
< y
.1 ,
'â– I
li
i,(
i
jF^^
jrm^L
m
Ml
ii fii<
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMAIMENT RFCO.RD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Jfro^/.s/r/'rd A'^o.
1 231
Dale Fih'il, LU-vQA^Uit 2.1 l''W\
ck^^K^uv^ cLtoM^ Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTK-Ci(y and County of San Francisco
Ccitificatc of IDeatb
PLACE OF DEATH: — County ofU/CL/Tv J .\XX^YVOv.^coCity of CJcL^ru J AxX/^^Tyyc^^^^i^^t^o
No.
'iOl VD ^^ra.d^^J^XA( St; I Dist.;bet.
/ ir DtATH OCCURS AWA1* FROM USUAL RESIDENCE Gl
\ IF DEATH OCCl. RRt D^JlN A HOSPITAL OR INSTITUTION
and
IVE FACTS CALLED FOR U*DER "SPECIAL INFORMATION" \
GIVE ITS NAME INSTEAii) OF STREET AND NUMBER. /
-v-^ )
-'â– ' (5?i
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
f\ t.'<>l.(iK
ouLa
O /(Xxk^\JL
y
/<Xaj^a^v\
i»ATi-: "I i;iKi-ii (Y7N
U\aX£
JXAr
/ "1 0 H
â– 111
MEDICAL CERTIFICATE OF DEATH
1) \ ii: t 'I i>i \i'ii
(M..nllii
(Dav)
(Vf.-ir)
*> U
MN'.I.l". MARklllH
\y\ IX >\\I<*|) ( »U !>!\'t I'.'i' I" I )
Hiurm'i.A'M-;
■^t;ili' . >! 1 •, ,,1 ,,) , ^t
I ATII j:k
lUk i II I'l, \iK
•>i r\riii:i<
ti| Miillll-. K
HIKTlllM, All-;
I III-:K!;I5V C1-;RTII-V. TIimI I atU-n.U-.l .Unvascl from
tliat Mast saw hrt^ alive on LLccO ^5" i,p S
and th.it ikatli ..ccnrred, on the date staled above, at %H5
U. M. Tlu- CAISI-; (U- I)I-:.\TI1 was as follows:
C3 OCLNXjLtj yJL\^JO\.-
••'■^'II' ATloX
A'.' i.lri! I II Sit II I '' ii
I "^ '
b 1/,..-'/., "X^ /'â– â– >
DCRA'i'ION
CoN'i'KII'.ITORV ULAJUUA.XXX
//our
-vx..
l.M' RATION );vr;-v
^p J
' Signed ) vL4vf>^ c
^b KjoH ( \(i,|ress) I'lOb
MoNt/is -' /)(irs
SPEG'IAL Information "nly f«r Hospildls, ln\fi(ulians,"lrdnsifnls
or Rfient Residents, nnil persons dvinq <m.)y fro.Ti home.
ih : ti<
- )V
iin: A novi-: st \ti: n i-kksonai, r xkikilaks aki; ik i j- t« » iii i
i!i;sr()i' MN' K\(t\\ 1, 1.1 )(,}•: and i!}:i,ii;i"
former or
llsudi Residence
When v*HS disease confrdffed,
If not af ()la( e of deafh ?
How lon(| .it
Pld<e of Oedfh?
Odvs
infill m;iii(
' \.!(h. ss
V
^
i
I M
\n'''(\ '" 'i'^'-*"'^ ki;M«.\ \i, I i.\ti:m! \uhi.m. ,,i h]:\u>\ w.
'\.l,l!.â– ^v
^' ^' Jivery item of !n?oriii(itIon Nhoiihl be cnrefully siippliL'tl. .\(iF. Hhould he Btiited HXACTLY. PHYSICIANS nhould
stntc CAlJSn OV DI:A TH in plnin terms, thnt !t mny be properly chiKNifietl. The 'Speciiil Informu tion** for par-
sons dyln^ nwny from hrunu sh«)iild he ^iven in overy inHtnnce.
i'^
:i^'
1 i
I
m
I*
iM
•'^J^
— 4 -«•
i
I
1
s
i
\A/R!Tr Pi A t Nl V \A/ITLJ I I ivi r A r\i ivir^ i Mir ,„^ -»-lj •<- • «-» » r«r-»^<
^^••1 »-»»^II^N^ 11^1%
i;..-i!.l •.( M- :.l!li 1 \"w \z. t'-Tss-^-". liSiV Cn
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dnfr /vAv/, lLcc<5^^ ab IfJOH
dU-L^^ dsJO\y^. Deputy Health Officer
Jieo^i.s/e/'ed A^o.
I
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of S)eatb
( X\. S. i?tan^arC> )
PLACE OF DEATH: — County oiUfO^/y\j OAxX/^v<XAec)City of 'd^Cu^v J >^lXwxx^v1<l •c,-c.
No.
.t
1 F DEATH OCCURS
-vaXc
h
St.;
Dist.; bet.-
and
KkWAv FROM USUAL RESIDENCE G'VE facts called for under "special information • \
IF death occurred in a hospital or institution give its name instead of street and number. J
FULL NAME
.^.^'CMj\; OorYVAAXA.^i'^A;
PERSONAL AND STATISTICAL PARTICULARS
"^'■•^ A . r(il<>K
.u.
\ 1 1. "I lilK III
,S0O
MEDICAL CERTIFICATE OF DEATH
' \ 1). < ii Di: \|-H
'Monllii
\' .!â– ;
H
M..}itli^
/',
--iN'i.j': MAKKiri)
W'llx i\\I'I» MK !>'\ . I'
I'-IKTMf'I.ACK
' St.'ltr or <,''.iillt t s
oJj^j^^^-Y\M\x M r^K
^^ I go M
'I)av) (Year)
I m-:Ri;i;V Ci:kTIl-N-. That l atlcn.U'.l .Uhvmsc.I fn.ni
\Xa.\^ 'X'h T<;oH to CLawVO a^D T90H
tliat T last saw liV^^> alive on LXaaXL QxS" np^i
ainl that drath orciirreil, on Liu- datt- stati'.l above, at 1.
V M. 'I'he CAISlv ()!• I)I:aTII xva^ as follows:
I \IMI.k
niKTiii'i. \t )•;
' " I N III i-k
"I M'iriii:K
iilKIHI'I, ACJ-
"I* M*>Tm.;K
-l:iN m! r.iimt I \
' " ' ' r \Ti' ).\
DCUA riON
( ( >\TR I l!r'l"( )R\
}'t'iirs
J A
\>nUn n) Pays
I lout s
•^V.^<1 ^^O.
%
C^vlO
Months /lav
5IGNED > kjUi. 6s..\iY\jLKyy\A^^
O^AL iNFORfVIATION
//(>/ns
M.D.
SPECHAL INFORfVIATION «n!y tor Hospitals, institutions, Trjnsipnts
or Recent Residents, and persons dyinj dway fron liome.
^W^^V/X
AV ill',! ; I! S,l t> I
I i' 11, ! 'I'll
C^
)-r„
M. iilh
1 '
I'lii: \novi-: ST \ ri:i) PKu>-.(>v\i, i'\u-|-irri, \K> \ki- jri ; ].. iiu-
lU'iST OI" MV KN(»\\ l.I.IXVI-; AN1> 15I':i,I l-! I'
former or
l'su.il Residence
Wtien was disease 'onfracted,
If not at place of death ?
flow long at
Place of [)eath
Davs
niifMnnriiit
( \-l.lrcs^
1;^<ACK ())•* HIKIM, OR ki;m(>\\i,
)Crw\X
LfccAAvojl Jb
xinCK'i-AKKK JyKjLMiw-^ ^J^XhJAJb
â– ATKof Hi Ki.At. or KHMOWAI,
'^'^' T90M
N. B..
-Kvcry item of informntion fthniilil be cnrefully supplied. AdB shouhl be Nttiteil TiXACTLY. PHYSICIANS hHouIiI
state CAUSE OP DLATH in phtin terms, thnt it miiy be properly cla»Ri1fled. The "Special Information" for p«r-
Bon« flyini^ away from home Hhould be jiiiven In every instance.
Si
i$3
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I
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lA/DITC Dl A I IVll V \A#l*rUf I I IVl CT A r\ I Ki r* I M i# _^ 1-Liie- •
■«*■•«
■viiif ^^ivir^i^ii^ ^1 I I « r%
Hc..i!.l i,{ llt;i!th- !•■No 1 5, S"-'3af:..-c-ii MS: I' (.'0
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dn/r- n/cff, [Xj^AyCiAjuik Xb
/fJO'i
lic^istcrod JVo.
i2.33
Deputy H^^afth O^^rer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Seatb
( 11. S. StnnC>arD )
J? (^ jp
%
PLACE OF DEATH: — County ofO/CL/T\' 0^uX/VLX:A^e<^City of U/CL/>-o J X.cl/^-^'Ca^
CO
No. bt: UJ CtCkLvajmxA^ LLx^.
St.; â– S'
Dist.; bet.
IH
and 1 5
/ O^ DEATH OCCURS AW«V FROM USUAL R E S I D E N C E G I V t FACTS CALLED FOR UNDER "SPECIAL INFORMATION • \
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
kXju
1' \ I I. < i|- lUK Til
\' .:
[ Urvr
\!..iit
0.5 r\
I I );i V )
as
s
.1/..*,
IS
'/(•.tr)
lhi\.
MEDICAL CERTIFICATE OF DEATH
DATi-; oi" I )i: A I'll
(Moiilh) ,1 (Day) (Vtarl
I III-RI-I'.V CI'RTII-V, That I atU'u.k-.l .leccascd from
to -r-r——— -:———.
--l^<.l,lâ– M\Klvii:i).
\\ii»i >u i:i) OK i»!\(>K(i:i)
'Wiitiiii >i<iii.'i! (i(^i«.Miati<>ii )
MIK I'lii'i, \ri-;
<Stat< or (/. iiiiiti \-^
N \M1' I )!â–
I- A rm.K
liikiui'f, \( ].;
<»i" 1 Arin:i<
' State or roiiilt! \-i
MAIDIIX XAMi
OI' MoTHKk
lUKIIII'I, Ali;
•>l' M(>'niI-:K
'Slati' «>r r.iimtrv)
LUrrw
~ 1 90 —
that I last saw h ~ alive
oil
1 90
and that <Kath occurred, on the date stated ahove, at
~" ^I- 'I'lH' CAISI-; OI- l)h;ATl[ was as follows:
DIRAIION
y
/)ar
Hours
X)\/y^'\X\y^
?
1
CONTkllU'TORV
IMR \TI()\
M()uths
^ CUi
1 I'AI'IOX p
KfyiiU'if in S<ni /'i ,iih '^ri>
XJ\j^r>n^<Xy^
J. \9->. UJ. kjiX/X/wAj \Ai\jtr\\j^ M.D.
â–º FECIAL Information nnlv tor Hospltdls, Instilutions, Fransienls,
( Signed
0
or Rpfcnt Residents, and persons dyinj dwdy froii home.
/h,
III ! \if()vi<: Si" \ rii> i'1":ks( »\ai. p \k iuti, ars ,\ki-: i'rik
i'.l.sT oi' Mv KN< •WI.I.DC )•; AM) IMJ.Il-lF
Former or
IsudI Residence
When was disease contracted,
If not at place of death?
How ionq at
Place of Death ?
... Days
•|() III)-:
' !lll<i' tllMIlt
I'l.AC}-; «>i- liiRiAi, (»r ri';m(»\.\].
DAT^loj' IM KiAi. or RI':M()\AI,
'^1 TQOH
(Address ll "^ 1 M^Vv^J^.-^.^^.^^^ ^-j^
I Ni)i;i
IN. B.
-I. very item olf informiition should be carefully Kiippliecl. A(iK should be stated CXACTLY. PHYSICIAINS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information** for p«r-
Ron« dyin^ away from home should be (^iven in every instance.
V.
1::
)â– â– â–
V}-
V
1.
ii^
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m
it '
\A/PITr PI AINI V \A/ITM lIMrAniMn INK
!»..:il<l..f ll.rilth \' So i- t^^"^ HSil' Co
TUic: ic: A or OA/iAiMr M-r cixrr^r\or\
• • • • ^i^ • ^i^ • • ■MM* • «■••• •• « w^ ■« • ■K ^am ^^ ^(^ ■V M^
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
:!
1<J0\
Bc^istered J\''o.
i234
Deputy Health Officer
i(
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Gcvtificate of IDcatb
i 11. 5. 5taiiC>arC> ;
J? ^ A %
PLACE OF DEATH; — County of 0<X^^ J^CU-yvCAl^cC^.r ^fO
No
CHi.
<\X
ty of^^XA^ OA/CL/>^.Xi>v^-Q.'0
St.;
Dist.; bet.
and
(If DCAt4 OCCURS AWAy FROM USUAL R E S I D F! N C E G I V f FACTS CAILFD FOR UNDER "SPECIAL INFORMATION ' \
IF DeJ^H occurred in a hospital or institution give its name INSTEAD OF STREET AND NUMBER. /
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
0 Ju^Y\-^cJL.^
\ri. « ii luk I'll
I,
ji
»l^
Pf
\' .1-;
^I\<. lI- W \\i K I I'D
\\ii)( )\\ 1- 1) MK n!\< »i-'.ri- !»
'W'lil' ill ^mial di si<'iiatii >ii )
IMKTIIIM. \ri-:
(St;iti. <>i I". HI lit I \ '
lA rm;R
I'.ik ill I'l. \ri-;
<)i" i\rni<:K
M \iiii:\ \ \ M ]â–
0 1-" Mi>'riii:K
lUR run, AC!.:
OI- m«iiiii:k
I St.itf or t"(,iiiili \-
' '• >1 rA'llON
h'flJfi! Ill Silll /'l.llh.''i
MEDICAL CERTIFICATE OF DEATH
iJAi'i-; oi- i>):Aiii
'Yi-ar)
yLT%'\.<X''Y\
I III-RI'IJV C1-:RT11'\-. 'iMiat [ MtteiKk'.l (Icivasc'.l fn. in
lli.'it I last saw h ^s^'v. ali\e on \-AXa-X3i Xb t^o H,
and tliat dratli orrurrcd, on the date- stati-d aliovc, at 1 HO
y^ M. 'I'hc CAISI-; ()!• I)i; ATII was as folldws:
t
I )r RAT ION )'nns
C'ONTRIIUTORV
Mo)iflis d^ Pays
//oitrs
rvLo>\;
DIRATION )\ors J/o>////s X Davs
^Signed ) UAilixA.A/v 0. vfL^ Oa/^v
^^ i(»oH ( Address) Ofc
flouts
M.D.
Special Information oniv for iiospii.iK, iiRiitutions, rrdnsients,
or Recent Residents, and persons dyin!) rtway fro:ii home.
Vwoou
y- .
M."!lh'
%
]'â–
'\'\\V. AMOVI-: STAri:i) PKR^^nNAI. I'A KlIiTI, \ R S ARI". PRl}-; To III 1".
r.I-;sT oi- MV KNOWI.l'DJ'.K AM) Hi:i,iv;i'
' Infi'inaiit
Former or
Isiidl Residenff
When w<is disease fontrarfed,
If not af pidfe of death ?
lloH lonq at
Plare of Death ?
I
Davs
'''"\\7)' **'f^ I!''»<IAI. OK ki;M<i\ AI, I DAI-i:.,!- Hini.ai. ..i R|-;M(»\ai,
N. B. Kvery item of Jnformntion hHouIiI Hl- cnrclrully supplied. AdJi k'iouIiI bo Htntetl HXACTLY. PHYSICIANS Hhould
state CAUSE OF DEATH in pinin ternm. thnt it may be properly cltiHHified. The "Speclol Information" for p«r-
Ron« (lyin^ nwny from home should be (i<ven in every instrince.
,'j
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A^
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\
iL JE -- aA- j^^smmii
rmr write plainly with unfading ink — this is jlj>e:rmane:nt record
l'.,rn.l -f !»' ilfh 1 \o ir *-^^^X-;iuS:l'Oo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
It
Da/c Fi/('(/, [XA^^yO^AAJ^ X^
lf)0^
lleghtcvejl JS'^o,
1235
cL^-v^^w/^
Deputy Health Officer
DEPARTMENT Of PUBLIC HEALTH^City and County of San Francisco
Certificate of IDeatb
( 11. S. Stanza r^ j
PLACE OF DEATH:
K f IF DtATH occursTawav troiJi USUAL
\J \ ir DCATM OCCjIpRtD IN A HOSPITAL
County ofO/Cl/Tu J .\xx^n^<iA^<:^ City ofO/
^
O^j'W) -J AXX<o^v/e-A^xj.Ai^
<xl St.;
Dist.; bet.
"2rrKt
L RESIDENCE GIVE
OR INSTITUTION GIV
mgjic
jlnriF
II
i
\ \
FULL NAME
FACTS CALLED TOR UNDER "SPECIAL INFORMATION" "\
rE ITS NAME INSTEAD OF STREET AND NUMBER. )
XXy
^y\Jl
PERSONAL AND STATISriCAL PARTICULARS
"^ Q'TvL
^V
ajL^
i» \ I i "t r. I Kill
\' .1
IX
X
5-
M.oitin
MEDICAL CERTIFICATE OF DEATH
DATi-; oi- i)i;\rii r\
(M()!iHi) i\ (Day)
r9o\
(Year)
\%
/',/!
^I\< .I.I". M AKIv ii:i».
uiixtu I'D (»K i>i\()Kri;ii
\\'iit> ill v,,iial <!< sij.' iiat i< •'! '
itiK riiii, \i-j-;
IStaU <ir foiiiitrv^
N.XM)' (II
!•• ATM IK
IvRI:P>V CI;RTII-V, That I attfiickMl (lecx^ased from
5" TqoH t(. LIaxxj. Q^.'i T90 S
lliat'I last saw hA/>w alive on UsAA/Ql. '^'h 190 H
and that <U-ath occurred, mi the <hite stated above at ^-S^O
J M. I he CArSl-: ()!â– I)i:.\rn was as follows:
\J AA.JO-VN'
-O-'VvA ^ -vv-A^-Ov/O^-AX^-'aA.x)
^1
I
Hi
e p r
' " 'IT \ lloN S[ 0
ck^T3LA>-VNwil>V
/\f'^:ilrtf III Siin /'i ,1 in i^f'tt <Tv )'</'»
MIK IH I'l, \i)-;
<M I \ llll'K
^; il . i ,; I . .11 n I I \
M\II>i;\ NAMl
01 MOTllliK
MIKrill'LACl-:
<>l- MOTHI.K
'*^tat. ..r (."(Hint 1 V '
DrRA'i'lON )'rurK
C'ONTRIIU'TORV
(Signed) J
J/ou/Z/s
/)(!].'
'S
Hours
^b T()o'^ r.\(Mrts>>)
Mouths Pays Hours
^cvvt M.D.
vCo"
0-<L^
i±
Special information «nly for HMipitals. InstitiJlions, Irdnsients,
or Recent Residents, and persons dyinq ,ih,j> froni home.
Former or
UsiihI Residence'
(Vu L ^ How long at ^ ^
e\J I UrVyXO/WCL ffO ^vc^pidre of Deatlj ? II Days
Monti,.
l\l\
I'll I'. Miovi-: s r \ ri: I) i-i-; rsonai, tak rhiiAKs aki". TKri': r<> riii-;
ni'.sl' nl' M\ K N( )U l.l'.DC.H .\M) m'.lji:!-
' 111 f'l, ?iialil
Wfien was disease contracted,
If not at place of deatli ?
I'UAri', 01 lilKIAI. OK R1:M()\AI. j DATI.o! I!iri.\i. oi K I-:.M( »\- A I.
r M » 1 . k r A K !•: K
(
N. B. F.very item olr' inltormiitlon nIiouM I».' cjirefully supplied. AOfi hSoiiI«I he stnteil fiXACTLY. PHYSICIANS should
stntc CAlJSr OI" DI'ATH In pinin terms, that it mjiy ht* properly claHHili'ied. The "Special Information" ?or p«p-
•ons dyin^ awny from home Hhoufd he f^iven in every inHtnnce.
f:
\ :â–
\\
I I
H
:i^^
If
i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
•=■■-■-' US:!' ('-
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Boi^isfrrcfJ jYo,
XQ06
\jy^<j^ JouvM^, Depjty Health '^ cer
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
PLACE OF DEATH: — County of^^a^v .3 Va
No.
Certificate of Benth
( "U. ^^ ^4nn^nr^ )
^\cc'i.c< City ofv.'<X>^' 0 A.a.^xo<.c\ c r
% 0
W\d db <X^^^^^ c X St.; 5 Dist.:bct. I C) Uv and 1 I .t]
(ir DEATH OCCUR*; AWAv rRQv USUAL RESIDENCE Givr tacts CAiirn roR unper speciai in'-crmation N
ir DEATH OCCURRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTFAO Of STREET AND NUMBER /
FULL NAME ^cIwkxvcI' H ' '-^<:^.v<xLl Jaa\^x>a
Iv
PERSONAL AND STATISTICAL PARTICULARS
\\\ols
loLtc
MEDICAL CERTIFICATE OF DEATH
n \ n « >i i>i' \ 111
1 ' \ I I 1 •! l;!K 11!
t
M 0 ;S
iMoiUlO (J
I iii:ki:i'.\ ri:!<Tii'v, rii.u i ;iti, n.K-.i ,i, . , .^.•.i imm
lb
:i
M \Ki< n:i)
\u i'« »\\ j:i» ok i):\oKri-:r)
i;;i< 111 I'l, \ri-:
(SUitf or C'uintrv^
liiK 111 fi.A'i-:
<»l- 1 AfllKR
M VilMvN N WW
<'!• M<»rm;K
<1^ 'iH l.,nS 1o LLc.VO 'XS 1<)0S
.ili\. I'll vA^CV-<3 3k S T()nH
Ili.l1 I l.isl saw li ' ^
Mill that (K-Mlli Oil II! ic.l, nil tlu- .l.tlf '^tatotl m1>ovc. at S
AI. '\'\\v C\l Si'! Ol- Dl.xrii was ;,-. Inllous.
!>
0
"^^ CrLch^o
in K \ IK )\
C ( t\ rU MM T< >
I » r R \ r h ) \
)'.//^ l/.'7///s I /).n s 1^ //,v^;v
) , ns
(^
SIG
NED ) dtv^. '}VlIUv.\ nv
M.D.
HfK III IM. All-
•»l' MoT||!:k
' »' >■I r \ii< »\
â– CUXCyCV>OLAj V^<X^Jjji
SpecKal Information '•"'* '<>' H'isni(.iis. inviiiuiions. it,insipnis.
cI/al INFOR
\.Mh.o S5 I - ?, vd. \\
or RnrnI Kcsiilriils, .mil prisons dvini) ,m.)\ Inin homr.
/\r' hll-il III Silll /'l(IH,l'/'i>
)V,M- I 0 1
10, /
111' \!!i »\ I" s r \iTi) ri-Ksi )\ \i. r \ I-: rnr I \Rs A K I-. rk r ]■; k » riii:
I'.i'.si" m M\ Kx» »\\i,i: !»<■. !•; AM) iii:i,n.i
' NiMtcsv;
IHlio
/OJAjVA,XL^rV\; > Jt)
lormrr or
lisii.il Rrsirfrnrp
Whrn was disp,isr i nn(r,i( Ird,
If not .il plrfrr ol dcdlh !
lloH lon(| ill
I'Um- ol DrHlh.'
n,i\s
i'i,\ri: Ml r.i I-: I \i, t »k K i-Mt»\Ai. I i>\'n-..' lucivt m ktmoxm.
r\i»i',K r \K i;iv
>"• ». livery item cif iiifortimtion should I).- cnrcnill.v s\i|»pluMl. A(if; h'iouM I»o stilted I.XACTI.Y. PHYSICIANS Nhotilil
Htiitc CAIISF: OF DHATII in pljiiii terms, thnt it miiy he properly cliiMHili'ied. The "SpccJnl Infonniil ion" V'or par-
sons dyin^ away from home should be t^iven in e\ery instonce.
I :1
'I
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1 /
■.1 i »
IP-
'ii:
it i'y
''lie
I
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• ri
I I-
if •.
•
1
jrtfSSMKL
i
.!
f
If
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
!• i!.' . ! II ''1;
"^i'^.
HM- C,
hafc Filed , LLoLXXA^^^Atj
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
X\
VJ()^[
Tieo'isfcred J\^().
1 2^7
<KAA^
Deputy Health Officer
DEPARTMENT OF PUBLIC IIEALTH=City and County of San Francisco
Gcitificatc of S>eatb
( Xl. 5. 5tan^nv^ j
PLACE OF DEATH; — County of ^ ' Ct^^- vJ/y^<X^vc.\^coCity of O ^x/y\j J Axx^-yx/e^^ ^ o
No. le^ll vJ^'lt St.; ^ Dist.;bet.UjxWtj2A; and Oxa1/>VV<jVC )
r IF OE«TH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALUEn FOR UNDER "SPECIAL INFORMATION" \
V IF DEATH OCC'JRRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER )
FULL NAME
.M;
A.'
aJIAxx.
/>\)
PERSONAL AND STATISTICAL PARTICULARS
COI.iik >
^ > • < ■: i;IK 111
.L'. IxCt^
I):iv'
1 '^ I
/ I â– ^
MEDICAL CERTIFICATE OF DEATH
DA 11. ' 'i I»i: ATll r\
LUm3 XI
(Vrar)
\' . \
1%
X^
/v
â– -I"'-' .1.) \! \ k K 1 1 1>
liiK I Mi'L \ri-:
' St;it<- or (.â– '.untrv '
OJ\Aj^JI^<^.
N.v\n . Il-
l-ATI n-.K
IlIR IMl'l, \( H
<>I" M'»TFI1<"K
I m;Ui:i;\- CIUTII-W Tli;it I .illcmk.l .Ic-cvast-.l In, HI
lli;it I last saw li XHj alive- on
IqO
ui'l th.i! iKatli nccurrc-d, cii tlu <\aU- stated ahovt-, at i-^ 0
LLjI. Tlu- C ArSl-:x»l I»I-:ATII was as follows
'\.xxJO
DC RAT I ON
) 'fiij-s
Mo)illi>
il
Ciyv^'^Nxo.
4-<r1a,
CoNTRII'.rToRV
f\ns lo //ours
\\
1>IR.\ TION
f Signed )
A\'
â– I INTioN
)V<//\v .}/(^N(/is 10 /;,/,. V //ours
M /\<X^ Q.ccWwx^A^- M.D.
LU^Q ^1 l.,riH f\.Mnss)5>oO 0
SPECMAL Information onU for Hospitals, InsllHitions, Transients.
It
or Recent RcsidentN, and persuns dvini ()w,iy fro:ii home.
M -nllis
I
I'm: A!!t i\j-, sr ATI!) i-kus,, )\ai, i- ak ricri.AK'- aki rkii' To rn i-*
i;i->r 01 Mv K N()\vi,i:n<,K and iu;mi-:k
Former or
L'sual Residence
When was disease contracted,
If not at place of death ?
How lonq at
Place of Death ?
• Ddvs
'lii *"â– â– â– in-iiit
( Vrldl. ss
I'l.Aci-: (M- inki \i. (u: i;i:Mf\Ai, dati-;..: m kiai, <.i ki.:m()\ai^
L\jLA^k^.x^:twM Laa/^ X^ T90H
INDICR TAKI.R
N. B. Kvcpy item olf inf irnmtion should be cnret'ully supplied. AGE should be stated FiXACTLY. PHYSICIANS should
state CAlISr OF DEATH in plain terms, that it may be properly dassilfied. The "Special Information" for par-
sons dyin^ away from home should be tii\en in every instance.
M
I <
' w
I
t
1 • :
I •
I • <
I •
Il:i
^ !
MlA^CWLt
^< I
u
*
V
WRITE PLAINLY WITH UNFADING INK
ti^^.t ..( II .'ii, 1- Vo
^ ■<•«;: liv^l' C
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
lid^lstei'cd J\^(),
1 2:>8
Ddir Filed. LLvvQAAAfc "XTX 100^
i^M.,*.^ iou>^ Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
PLACE OF DEATH: — County ofCj<Xy>X' 0 X.(X'> vc<.<n.c.c City ofO/Co^. 0 A.<X/w Cu^ c o
No. 5^ Lfr^x^\HL/x.<Li... St.; S' Dist.;bet. ()b OJv>l>UL^>\, and vD.>jj^/-> t )
/ IF DEATrt OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION \ jl
V iF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J (J
P
FULL NAME
CL
o
I
cxX
\X.\.C
PERSONAL AND STATISTICAL PARTICULARS
â– i:\
â– ro
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liiu riiri.ArH
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( â– . .'1 hi I V
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ni Morin: K
I'.iK 1 iiri.Ai 1.
••I MoTiniK
' Si' ' <.'>)ll11tl \ I
<H\1 !• \ rioN
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATH
as
fDavl
^S~ i*,o't
(Month) /f fDayl (Year)
I lli;kl';il\' Ci;UTil'V, Tli.il I attcn.U-(l (Icciasod liom
LLla^Q 1% npH to LVaa^
tll.'il I l.ist saw li i. â– alive oil LLv,\^Q^ ' k"^ l(;o'^
ati<l that (k-atli occunc(l, 011 tlu- dati.- staled aliovc-, al I 0
U^ M. The- CAISI". ()!•■hl'.ATll was as roll.iw^:
J
^\Xl.*wV.A-^ S!..
1)1" K \ rioN
VJ
)'(ars ^ Mt)ntln
c 0 N T R I lU r ( ) R \ \>(y^.Xx,^'\..>S.
Pax
//ours
DIRATION
(SIGNED) lOAyj.
)'tiir.s J A '///// .V
Pay
rioH
rs
Rf!!iiff(f lit Siiii I'liif, ' (-.) .X,
) ,
^ M.u'Jr-
!
riir. \H( »vi: sT \!'i- 1> i'i'i<«^< i\,vi, !• \K rini, \ Rs \ki: i'ri )•; r< » riii-:
iu;sr(»i- Mv KNM A i,i:i)c, 1-: and iu'.mi,!
(Inf^ M
Ir
U.U M.D.
f) i.,o'i (Add ass) ^ -5 lXvl<X>vh_^Uj Vi),t<^..,q
SPEOIAL Information only for llos(iif,)|s. Institulions, Irdnsienls^
01 Rt'ifnf Residents, dnd persons d)ing dw.iy froii home.
Former or
Usiiiil Residencf
When was disrasp ronfrarted,
It not al plare of death ?
HoH lonq al
Plare o( Deafli ?
Oavs
I'X, \ri-: (»I' HtKlAI, <»!< Ki:Mn\AI,
CrLu \Ka
0 K
DA 11: '.) Ml RIAL .ri K i;M( i\AI.
T9n'\
I NDi: I
N. B. fivery it.-ni of in)t'<MMniition hIiouM \v: CJireV'iilly .supplied. WiV. s^ mlil bo Htnteil EXACTLY. PH\'.SICIANS nIioiiIiI
Htntc CAIISF or DI;A I'M in plnin tcpins. that it m.iy I)l- properly cliiMNiified. The "Spcviol Inliorimili'm" f«>r per-
sons clyin^ Hwuy from hoinu Hhould be ^iven in every inHlnnce.
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WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
lln^usfered J\^o,
i^^9
Ddlr AV/fv/, (X^,.^^cv^^ ^1 J'^O"^
eputy Health Officer
DEPARTMEiNT 01^ PUBLIC HEALTH=City and County of San Francisco
J^^^j-A^^VA^ ckjw^\>U
Certificate of ©eatb
11. S. ii'tnnDarD )
i
^
Ol^
PLACE OF DEATH: — County ofCloL/w- 0 /vXXx>^^v^'c€ity of *^Cl/>^ 0 . ^xx^kvam^^o^c^
No. l^V; \J\JiAy<Ui^'y^ LLvO. St.; lo Dist.;bet. VJ Cr\Xx^ andvD^X.
/ IF DEATH OCCURS AWAY FROW USUAL R E S I D E N C E G 1 V E FACTS CALLED FOR UNDER "SPECIAL I N FO R M AT 1 O N • ■\
V, ir DFATH OCCURRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
C<il,nk
\
D \ I i I >i r. IK I'll
I Mi.iifh I
\i . 1-;
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H
M.'iilh-
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M:i!< III (.â– (ilinllV
M \iiti:\ N \M 1
Itik Til IM,.\('l':
•>1 Mol'lll-.k
' Mat"- 111 Count 1 \ '
x\
(Day)
(Year)
MEDICAL CERTIFICATE OF DEATH
D.vn-; oi" DivVTH r\
I Moiitli) K
1 lll{ki;r.\' tl'.UTII'V, 'riiat I attciuUMl <ic'roastMl from
HAjJLu l^" ItjoH to LA^^A.^ ^1. TqoH
that I last saw li-i-<^^^\ alive on UO-''^^ Xt ujo ^
ami that ik'ath ocrurrctl, <mi tlu' datt- statt-a above, at *"
M. Till- C.\l SI-; OI' l)l':.\'ril was as follows:
DIU A riON
)\at:s I Mo)iths I A Pays
Hours
' •' I'l !■\l'|( )N
) , ,,-; H yi. nths 10 /'.
IN, \i!f »\ i", ST vn-: !> iM-: k<.( »n\i, I'.xKrirr i, m<s \k i: rur i". r< • rii i:
iii.sr OI Mv KN(»\\ij;i)<; !•: .wd in:i.n:i
f InriciiKiiit
CONTRIHrTOkV
DrU.xrioN Years I J/<';////.s 1^ Pays
iNED) OX^ Vj. vI .o^AjLtU^^^
(SIGI
l^L^
^
UUv/Ol'X'1 KioH rx.MtvsO HOH- ivd.' Ot
^v/0, Vs I
FECIAL
i
Hours
M.D.
SPECIAL Information "f'y for llospitdls, institutions, Transients,
or Rorcnt Residents, .ind persons dyinj .iwdy Iroin home.
Former or
lsii.ll Residence
Wlien was disease rontrarted,
II not at plare of death ?
HoH long at
Plare of Death ?
Days
ri.Ai'i'. • >i- iMKiAi, (>i< !< i;M< "V \i, j i)\ri'. Ill m in,\i. m ui;m( )\'.\i,
INI ) I ; K T A K 1-. k OVO . 0 . O-^^/^JhJv ^*^ Lo
N. 1$. I.very Item ui intform,iti(»n Khoiihl be cnroViilly suppHlmI. \V,V. should be stj.teil liX AGTLY. PHYSICIA^IS should
Htiitc CAlISr. OP DI A Til in pliiin lenns. thni it mjiy be properly claHsitied. The "Specinl liiformntion" for pur-
Bnn« (lyin^l tiwtiy from Ikmtic should be ftiven in every instance.
A
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J»ft^'-'%t, liiS: I' Co
THIS IS A PERMANENT RECORD
r
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
1240
Ecssi, stored J\''n,
/>,./r /7/rr/. (Xouxw<i±i 3.1 l''0'\
l^^^lwM, Deputy Health Officer
DEPARTMENT OFf UBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( tl. S. Stan^niC^ )
PLACE OF DEATH: — County of 0 /Ol/^a; J AXX^ vvt^..,^L^ix City of ^/O^^^ 0 A^v^ <^va.'^-^
No. ISOlo
St.; to Dist.; bet.Mx^rv^^^^VVvKXAV^^ and
CALL
NAM
v-vW. )
/ ,F DTATH OCoVjRS away FROW USUAL RESIDENCE give facts called for U N DER T SPCCIAL INFORMATION' \
( °F DEATH $C-!rrTd IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OfI^TREET AND N U V. B E R . J
FULL NAME
.Ouy^^^ouO^'Ou V
\:
>l:\
PERSONAL AND STATISTICAL PARTICULARS
xrVCLc
Ii A ri". < U I'.IK III
\' . !•:
'JOZ.
M.Mltlll
1% .,„,. ■(
as
( Day)
M.'nilr
\ cur
//,/
winow i:i) OK i)!v<)Kii-:i)
^Writf ill -uciiii <1( — iL'tKition)
-V'Xajl/cL
lURfHi'I, \'lv
'Stat' â– â– â– 'â– Miuitrv
NANTJ- ()l
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OI' l-AIHI-K
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MA I DI-.N N \M1',
ol MoTHl'.k
t)l- Mi)Tin:K
(Stilt'.' or Coimtry)
O^^y^y&j
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crpA rutxCMP
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iin: xiiovF. sTAi"i:i) rKRsoxAi, r\Rrn.M'i.ARs ari' rRri*, to tin'.
HKST Ol' MV KNn\Vl<i:i)r, K AND lUn.nCK
(Info;ni;nit
S 0 b Lbv/^^-vu, Ot
f \(Mn-ss
4
MEDICAL CERTIFICATE OF DEATH
3vO IQO '1
(I);iv)
(YCMI
DATE OF Dl.ATH /""l
'Month) K
I II i;R i:r.V CI.RTII'N', That I aUiinKd lU-ocascMl from
LLl/l/Q ?v i<)0^ to \Xx.\yOi Qsb T(,o H
that r last saw h -^>^ alive on LLowXX ^0 Kp H
and tliat .Kalli occurred, on the date stati-d al»ov<\ at O • 6 C)
\J M. 'flu- CArSI'! Ol' DI'ATll wa^ as follows:
I ) I â– 1>J A T I ( ) N ) V(^,s- 1 Mon th s /)ays I/i. ) ii t s
I )r RATION
^t'o}lt/^s I^avs
/fours
M.D.
Special Information only tor Hospitals, institutions, Transients,
or Recent Residents, and persons dyini] away from home.
(Signed) Vj . o.vijA>.^oh
Former or
Isual Residence
When was disease contracted.
If not at place of death ?
How lonq at
Place of Death ?
Days
PI \CF or HTRIM, OR Rl'-.MoXAI, DAri"..;" P-ikiai. or R1:Mo\\I,
!N. B. F.
ivery item of Information should be cnr.fully supplied. AGE should be stated f.XACTLY PHYSICIANS should
tate CAUSE OF DEATH in plain terms, that it m:.y be properly classified. The Special Information for p-r-
sons dyin^ away from home shoulil be Jilven in every instance.
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PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
iyi=5&x
\ik]'
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
t"
/)///(' h^l/cd ,
(X.^^'VAA^
'X\
lOO'i
Be^islcred J\^o.
I2il
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( 11. 5. 5tan^ar^ )
J? (^^ Si (^
PLACE OF DEATH: — County ofCj^OyYv OA,cX/^vcui.uCity of d.O./w OAo^^'AyCUixOe
rNo 10 0 0 CoJ.JlA.- St.; I Dist.;bet. 3.5 11^ and ayUA^
/ ,r DEATH IoCcIrS away FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER SPECIAL INFORMATION ' \
( .r deaIh o^c!rrTd ,n a hospital or institution give .ts name instead of street and number. J
FULL NAME Wiv. , OX<L^i^^-J^ OAJl/>^'
)
''\J
-^
PERSONAL AND STATISTICAL PARTICULARS
rol.i »K
I
' A'\ (
4
DAI 1-: t>l- 111 K Til
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M..ntli
lb
,*\
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14
)
1 ',.;/,'//
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â– >â– ( ill
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^ INC. 1,1-: M\KKIi:i>
I Wi itr i
lUK Till'!. \fi;
' Stati ' .1 I "â– 'iinl I \
\ WW: t •!
iaiiii:k
UIK'll! !â– !. \r}-:
ni- iArm:k
I Stiitt or Country
M \!i>i:n nam 1-:
<>!â– Mit'l'lll.K
lURTHrLACK
ni- MnrmCR
(state or Contitiy^
< HI I I'A TlnN
l)
<^
A/vvX<LX!-'Vaj
ex. w ^
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J AyCu>xALJU H I- U/CU-Y^-WOI.
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/',â–
THl'. XltoVl*. ST ATI. I) I'K K-^* )NA I, r\K TIvri-MO A K I ". rKll-; T( » Til l'
iu:sr oi' Mv kno\\ij:i)«;k and iu:i.n:i'
IIiiroMnrint
( \.l<1r.'^s
(W-ai)
MEDICAL CERTIFICATE OF DEATH
DAT I", oi di;ath r\
LLc^o It
(Month) /] (Day)
I 11 Ivk I'iliN' (>.' !;R'ril-'V, Tlial I attc-iulcd dcrcased from
NtAjULc*. Q^^. i(,oM 1(1 LAaa/CJ^ Xb i(,o H
tliat I last saw hA- ..« alive on L*-*-v,n Al jcp '^
and that death occurred, on the date stated above, at ^.^ 0
y M The CAl'SIC OI" DIvA'I'H was as follows:
^'
])\'K.\'V\OS }\'ar.s- I Months O Pays
C C) N T R 1 1? U '1' () R \' LI y>J>l/v:
I louts
v.^-«:.^«^-r:v^^
I )!' RATION )V(/y.s- Motilhs Pays
( Signed )
a
CLQ '^'l U)o'
a.
O Ol/*>a^*n_U.i
Address) ^'o5'C)<X/W
Hours
M.D.
La\X^<i Ia.\-
SPEcilAL Information on'y '("â– Hospltdls. Instilullons, iNnsients,
or Recent Residents, an-l persons dying dway frnn fionie.
Former or
Isudi Residence
When was disease contracted,
II not at place of death ?
How lonq at
Place of Death ?
Days
IM.ACIC OI- HIKIA;^, OR K1;M(i\AI
^uW\JLA>'
^Ola-O-O'^
DA 11'. of I'.iKiAl. OI K1:M()\\I,
Address .Q^H\'s5 M f\A><lA>A.-<r\X ^ J.l
N. B._F.very Item of InformBtlon «honld be cnrefully suppllod. A«H sV.uM be stnted BYJVCTLY PHYSICIANS should
«tntc CAUSE OF DEATH in pinln terms, thnt It m;.y be properly classified. The Special InVormat.on Vor pT-
sons dyinft away from home should be [ftiven in every instnnce.
If
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^â– ri*^^^*-- '
IXf) :^ t-^^^r.'^'-^; lU^ r C*o
— THIS IS A PERMANENT RECORD
lEFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Eeo^Ls'fe/'pd J\^o.
1242
l)>i/,- Fi/rr/.iXj.^^-^^^ XI l^'C"^
Lr^^lc^ Deputy Health Officer
DEPARTMENT OT PUBLIC HEALTR=City and County of San Francisco
Certificate of H)eatb
( XI. S. j5tnn^nr^ )
J? Qsp A ^
^PLACE OF DEATH: — County of CI^La^ J .^v^u^c^a^ City of O/Oa^ OaxVyx^a.<l^o
N^ 0^\^ JUxi^'v^.^^ ULvOL V \^ cu.,, St.: \ Dist.; bet.
and
^^ A \, iiciiAi ^rQinrNCP nvE facts called roR under special information • \
FULL NAME
oo
' I . \
DA ri-; n) lilK I'll
\' . 1-.
PERSONAL AND STATISTICAL PARTICULARS
IX'
,kXjl
M..iUh!
il):ivi
(Vcn)
)•-„•/
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si\«,i.iv MAKi<n;i)
\\I IX >\' (• ' ' ' "■' I • '\t >»•' k' 1'. I)
Wli!
MiKi'iM-i. mm:
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N \M1, » »!â–
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St;U<- (It Ir.MllIt V'
M \I1>I,\ \ \ \1 I
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<>!• Mt>Tm-;R
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lU'.ST ()1- MV KNi i\\ l,i:i)C. !•: AM) I!i: M J-". 1-"
nnfM-m.'nit
ySoL/vtoL H. <5vJuL<^
\.1.1p
,VALUa,x(i)o^ tit
4 — ^ ^
MEDICAL CERTIFICATE OF DEATH
DATI-: Ol" DKATM r\
(Day)
/OoH
(Vi-:irl
(Month) /f
J Hi:RI":r>V CI'.RTII'N', 'I'hat I attciwU-cl (lercastd from
tliMl I last Saw h -0%^a alive oti LL\..\^ 'Xb up
aiiil that «lL-atli ocruric<l, on tlu- datt- <tat(.-(l alxivr, at
M. Tlu- CWrSJ': Ol' Dl'lATM was as follows
nr RAT ION )'riirs MiUilln Pays
//ours
CONTRIIU TORY
DIRATION
(SIGNED) ^
,v^
)'rars M<>n(/is Ihivs
vJLwvtc^ro
LL^ -^^n i.,oH (\,l.lns.)ll><tt VJb
^
//ours
M.D.
SPEci^AL INFORMATION ""'> '»'' Hospildls, Institutions, Irdnsients,
or Raent Rt-sidents, and persons dyinj .iwhv from home.
Former or
Isudl Residence
vvfien was disease rontrarted,
II not at p!af e of death ?
How lon() at
Pla( e of Death ?
Days
n.At"!-: ol HI \< I A I, OK kl.MtAAI,
) \'\'V. "I r.! iM \i. iM K I'.Mt i\' \I.
N I ) ]â– K T A K 1-; K I) oJU/vdjL M rUuVA./VV\j^^ L^
(Acidise ISX^i uLiyTJkXio
>, .. I- 1 \f'|- ««i.,ulil he stnt'MJ i;\'ACTLY. PHYSIC! \NS Hhoulil
N. B. nvery Item of Information hIv.uI.I be crcfully Hi.p,»I.ecl. A(.!. k i.ul.l »^.^..« 7' *-:''::. J* .. , ,,„.„^„,at5o„" for p.r-
statc CAUSE OP DI:ATH in ph.in terms, thnt It m^y he properly cl»H«.^.cd. The Spcal In.ormat.on »or p^r
«on« dyin^ nwny from homo should ho feiven in every mHlnnce.
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ITH UNFADING INK — THIS IS A PERMANENT RECORD
1 N.
•'^"^X^Wb^VCo
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dale Fi/c'l , vJ^aa^OA-v^ '^1
loo'x
Re (ii, si ('red J\i''o.
1243
.^^^ Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Gcvtificatc of ©catb
( *a. S. Stan^arC> )
-p
^
PLACE OF DEATH: — County ofO.a,^ J.V<Xa^^c^c.c. City of ^ '<Xa%. J A.<Xov<:a^^<.
N(
i 4
fP
St,; 3. Dist.;bet, OX^cJcU^v and ^ CKA>
-\A>V^ \^V^_ V ) VJO T - -V. oF«?IDFNCEGIVt FACTS CALLED FOR UNDER "sPtCIAL INFOHMATION" \
( '^ r."o;ATH^OCCUrEV,;"rHo's^yT'At o""N?.',TU^4"^0,Vr.Tl NAME .^STEAO OF STREET A.O .UMBEH. ;
FULL NAME
C^lOXO.:
it
\.0l<L^<Xa1.\a.
Xx/^^vcu^ccL I
PERSONAL AND STATISTICAL PARTICUBARS
^ (1 ^""-"MoJ ^
vJX/
HA 11'. < )1 I'.iK I'll
K-KX
I MEDICAL CERTIFICATE OF DEATH
DA ri", Ol- I»i;A TH , ,
M|.;ith'
Ai .1-;
\%
) â–
I
IS
II).1V>
,!/.â– ;/.'/'
I Year)
X
/'.
SIN<, !,,' M \UK ll'.n
wii)( twi-.i) ok i)!\«>Kri:!)
iW'iitt in MK-ial (Usij.Miati<in)
i;!K rm'i. \r)-:
St.-iti- ' '• ' '■ill III ; \
N WW. Oi-
I AC II i:k
I'.IK riMM.At'K
(>!• FATHlvK
'â– Stal'- 'ir <"'Min1i %'^
M MDI'.X XAMi:
(»1 MDlin-.K
lUKTnri.Aii-:
Ol" M(>tiii<:k
f stall- or Coiinlrvi
•nrri'ATloN 9 n
\ )•,-,.'<
1 A. /////>
/',;i
Tin-: Anovi*: sTA'n:i» phrsoxai. i'akiuti.ak^ aki'. rKii-; t<> rm-:
IU-:ST Ol" MV KNo\Vl,i;nC. K ANP Itlll.Il'.l'"
f Info: in.'uit
%.
^^.kJL
( \.l.lrc^s
i
H I ^ CJ /OiyC:/\XX^ry^\Ji^v\X<
^
(Vnnih) K <I)ay) (Year)
I lilvKl'.nV Ci;U'ril"V, That I altoiidtMl (Icci-ascd from
^
-\
tliat'l last saw h •>••' alive on LX^-^ 0.1 up H
aii.l that .hath < .(â– currcd, on the tlatf statc-il ahovc, at
M. Tlu- CAI SI', Oh' i) MAT II was as follows:
1
DTK AT ION
CONTRIIU'TORV 'uJ-ryyJ^r^y^^
Ddvs
J Jours
DERATION
(SIG
)'i'ijrs
Mo)it/)S
/hrvs
CLv^ o.n Ton't f A.hiu-.^) Hob 3:c^tu>v< i.t
Hours
M.D.
»E:dlAL INFORI
SPFdiAL INFORMATION «"'> for Hospitals, Institutions, Transients,
or Reien] Residents, and persons dying avv.iv from home.
Former or
L'sual Residence
When was disease rontracted,
II not at place of death ?
How lonq at
Place ol Death ?
Days
I'J.ACK Ol' nt'KIAI. OK kl'.MoX \I.
dbcrW
Ou^AA'
DAl'i; 'i!" lii Kl\l. or KI:M<»\'AI,
1 1
(A(l<hess ^ XH
.N
II ATF ahoultl be strtteil RX4CTLY. PHYSICIANS should
. »._-F.very Item of Information should be cnrcVully suppl.ed. ^''^'l^^^'^l^^^^ ..Special Informntion" for p-r-
Htate CAUSE OF DEATH in plain terms, that it may be properly classified. 1 ne ^i
Rons dyini away from home should be j3>i>en in every instance.
%
\ â–
li
r. *
r
m
'ill!.
i I
li
m^^
-^^mtk/
.^^%9^
WRITE PLAIN
LY WITH UNFADING INK — THIS IS A PERMANENT RECORD
II
)i
,! ,.f Ur;iUh— 1- Vo, IJ5 T*
â– *.'
^o •«<«»,
•-; HX:l' ^"
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Jip^f'^sfrred J\''f)-
1244
cer
ty
Hair niol, \X^J^OA^J&i Xl I'X''^
\Jy..J^^J,\x^ Deputy Health Off!
DEPARTMENT OF PUBLIC HEALTH -City and County of San Francisco
Certificate of IDeatb
( tl. 5, ♦r1t^n^ar^ )
PLACE OF DEATH: — County of Oa'^JAxx^vtv^Co City of^J/O-A-v 0/uCX/YVXi^A.cc
f+s,.r. ^ni,._.i _„^ __.„,
No.
V.Lt ' '^
'>V^V(yU,A.^t.;
Dist.;bet.
i. 'I'*!
I
FULL NAME LcUa-^^ctvx:^
:(.;
>:â–
PERSONAL AND STATISTICAL PARTICULARS
1 • ; I ' ii l;lK 111 P
15^ r%'\'\
"1 < a r
\'.i';
Ho ,
\\
s
>>I\"<,|,K. MAKRIl-". IV
WIIM »\V1-!) OR 1H\'< >Kvi:i)
I Writ' ! n -. . i;'. I ill -''.'iiat i')!))
in K Till' I. \>"i".
â– St:it< nt I â– >imt I \
N \\U ( tl
rATIll'.K
MK rill'l.ArK
oi" l-AIHKR
(State or CDiiiiti \^
Ill Morni.R
lURTni'LAri-:
<H' A:t)'!in"R
(St:i!
' t-ClTA'l'IOX ^^^Sk^
fi/VW<X
:aXXA'V-
AXVW^C-X
"J
k'r~',frJ ill S,ni /'i ,1 II, ; )-ri — ) .'<m
M."!f!l'
III-, \1'.()VK S|- A ri:i) l'KR-;oXAl, rARlUlI.^R^ ARK rKlK TO iH J'^
i;i:sT *>i .21N' KN»)\vM-;i)«'. ic and }'.i-:li1':i'
Address \JCL/\^/>u:iJv\Ayâ– \.'SJiUi.
'III riiiin.iiit
MEDICAL CERTIFICATE OF DEATH
DATi-; < >i' I'l WW r\
(Montht r (Day) (Year)
1 II i:U ivi'.N' C" i; Iv Til'N', Tlwit I iiltenikMl (Iccrasod from
LaJj^JVaX
that I last saw !i v > â– ,ilivc- 011 \JokA^ '^.'i Kp H
;in.l that death orourrcd, oti tlu- datr stated above, at o. 5 5
Vj M. The CATSI". <>1' Dl-A'l'll \Nas as tollows:
>
DIRAriMN )',ars \ M,)uths I 3 />,?i\
CoNTRir.l roRV
IliUlt s
DIKATK »N
(SIGNED r
) V./;'.<r
.1/."////
UU. X9. L^nrAXo^A.
/\?r
/fours
M.D.
_ A 5 I ( lO V f
vAAyvw^Jt"
SPECIAL Information ""'^ ''••^ Hospltdls, Institiilions, Irdnsients,
or Rffcnt Residents, and persons dving a\sa) \-.m home.
yjJ^yy^AJrx^
How long at
V^--a.->^ Plate of Death ?
. Days
When was diseasr rontrarfed,
If not at place of death ?
I'LACi-: 01 r.TRiAL OK ki;m<)\ AI,
DAii:.; I'.! HiAi. or ri:m<»\ai.
... .' .. II APF «Hr.iil.l be stated RX4CTLY. PHYSICIANS should
N. B. Fivery item of infarrtiHtion should be carefully supplied. At.F. sHoi.I.I ".^^.^y'^^ "J^ ^^^ i„f„n.««t Jon" for oer-
Htate CAUSE OF DEATH In plain terms, that it may be properly class.t.ed. The Spe.-al InVormat.on for per
sons dyinft away from home should be ftiven in every instance.
W"
H
{ ;
i 1
(I
f!
M I.
B'l
'*
^
WRITE PLAINLY WITH UNFADING INK
iu^«l^4ii;i'.tli 1'
fi"*^*"^
l)^^^^' Filed ^
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
i,9(9H
li(>(^istci'C(l J\^().
12 m
CX.'tr^.A.^v^
Deputy Health Officer
DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( "U. 5. tr»tnn^nrD )
^
m
PLACE OF DEATH: — County ofCJ,<X^r^ J A.a.-yx^A^-oCity ofU C^/>x/ 0 . Vo.^a.'e.^.^^
St.;
/ ,r orATH OCCURS AWAV TBOM USUAL RESIDENCE a.vr pacts called ^o" ^.^^rR '^^^ll^'^^^^'^^Zl'^''' )
t IF DCATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEA^ OF STREET AND NUMBER. /
FULL NAME
.UUv\xo 0\D^Uw\^A..
PERSONAL AND STATISTICAL PARTICULARS
AJ
4-
y
l;lK 11!
r I '- â– '!
M.iiil!!
\' . !â– :
45
)â– -
1 Dm VI
.U.»i///~
â– ,'v:i! I
â– -IM.J.i: MARKU'I)
\\ Mil iwiTi < >u i);\'Mvr i", l>
111
\\!i!
1UK rui'i.x^M':
st:it>> ( ,v t â– unit I \
NAM J, (>1-
I- \Tin:R
luR'iii I'l, \t }•:
or i\rni:R
' St.ttc or C'otnit I \
M MIU'.N" N \M1.
'il MdlMll'.k
inurnri, M'K
<»i Mi)Tni:K
(Slate or Cnnnliyi
'■' I I'A ri» IN
OS?) (j
^c
)V
M.'iit/r
/ â– .M
TH!'. XHOVH ST ATI- I) I'KUsONAI, J>A K T HT I, A KS AKl' TKIK Ti • nil',
i5i:sT oi- Mv KNowLi-.ixiH AND r.i':iji:i'
f Illfn:n);iTU
^
fA'Mress
\X/\>^.
(Year)
MEDICAL CERTIFICATE OF DEATH
DATH OI Dl'ATIl /"^
(M.)iitli> A (Day)
I Hl'iKl'J'.V CI:RTI1<'V, That [ attLMnUMl dcHxasotl fioiu
CLla^q ab looH to LLv.^^ Ovla H)0 H
that I last saw li •«-■alivt- on *^\.A.vV,Q >.v;.
itp 'I
iiii.l that (Iratli occiirrcMl, on the ilatc statt-tl al)o\A'. at ' '• ■oO
^L M. Thi' CM SI' Ol' I)i;.\'ril wa"^ as HjIIows :
DIKATION y<ai
CONTKlIIi roKV
.\/oii//is
I^ays
/Ion IS
I)1I< \TI()N Y''^'''^ Months
Pav
//(inr^i
(SIGNED )
Special information on'y for Hospitals, Inslilutibnt, frdnsients,
or Recent Residents, and persons dyin!j away from home.
Former or
lisudl Residence
When was disease contracted,
If not at place of death ?
How lonf| at
Place ol Death ?
Days
'LACK Ol lUklAI. OK Kl.MoVAI.
)JLv^1
I) A I'l; -))' I!! iMAi. or ki-;mo\ai<
\J,A>«^ O '^% I90H
INDl-.K TAKI'.K
(.-
« .. I- I APF «Soiil<l he Rtiited r.XACTLY. PHYSICIANS kIiouIcI
N. ^^, Rvery item of JnformHtion should be cnrefully HuppI.ed. AGE should ^l*-.***"'^;: ' \\r, . ,„w.„-,„„ti„n- ^^ p-r-
state CAUSE OF DEATH in plain term«. thnt it m»y be properly class.^.cd. The Spc.ol Information lor p-r
«on» dyinft away from home should be U'vcn in every instance.
I
I !
ii
4i r
I
m
1 1 '
It
ii.
H
«
WRITE PLAINLY WITH UN
.! ..r iic'.Mii I V'
FADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/)/(/(' Fi /('(/.
ai
VAA^
rs
!o:?fth Officer
lle<:>i,sicrc(l J\'*o,
1216
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
PLACE OF DEATH: — County ofVJ<X/>v
Ccvtificatc of Bcatb
J^
4
St.; X Dist; bet.
vuJ^C5\-U\jand 'ktPAX^
No. ISSH Cjo^cA.ayY>'vJi'^vl.c ^.„ . ,-- ., _, .
/ ,r DEATH OCCURS AWAY FROM USUAL RESIDENCE ClVr FACTS CALLED POR UNDER S P E C. A L 1 N FO R M AT I O * \
( Tf DEATH OCCURRED ,N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUN.BER..J )
\
FULL NAME^X^^vv o
Om^dU. fl^JUAJAA-^^O/rv-
i) \l i ( u- i:!K ni
PERSONAL AND STATISTICAL PARTICULARS
, L"< '1,1 >k
t .
X
%• ■■!
1 :i!
\' .1-;
^INT. I.K, MAKUn.n
\\ • itc in - • - )
^
'\ t
I'.IK I"!I I'l. \>' I-
NX Ml- (»!â–
lATii j:r
r.iR'niri. \f!-: h
Oxc ULV -^ '>^u,a_/T u'
'State or lOuiiti v
M \1I))'X NAM 1,
<i! Ml III! i: K
IMRTHri.ACK
"I MUTHl'.K
-tate or Coiniti \
V •
MEDICAL CERTIFICATE OF DEATH
DATK »>1 Dl'.AllI
Montli* i
(Day)
I go \
(Year^
I IllvK Ivl'.N' C IIKTI 1"\', Tliat I ;itUMi.U-il <lc(H'ase»l from
CLoon iO i9o'\ to LLv,v^ 0.5^ . TOO S
that r last saw li ••' alive on LL<-uQ. X-^ up \
;inil that (U'atli orciirrcMl, on t lie <lalc stated a1)ove. at I- Ao
M. 'I"1h' cat si-: Ol' Di: ATll \\a<i as follows:
DT RATION Yrars
coNTuir.r'rokv
Moiif/is '^ /)avs I/oitrs
Di- RAT ION
)'t ars
JL/C/kVCL^-V-
t
^ ^
I )• \l'li»N
llli: \I«)\-K ST \r}'I) I'KRSONAl, !• \K riiTI.AKS AKi: I'R! !•: I'* T'"-:
1U-",ST ()!• ^IV KN( »\VI,i;i)f.H AM) lU-'.l.U^K
Moil tils
^\ i, (^
Signed) J/vcin^^xx^ O.v.-, ^^^,.o
:cSal in
vt^<^a
f I ours
M.D.
SPECIAL INFORMATION t^"i^ ^"r Mospifals Instilulions, Transients,
or Rcrcnt Residents, dnd persons dviny ,m.jy from home.
Former or
L!sudi Residence
When was disease contrarted,
If not at place of dealt) ?
How long at
Place of Deatli ?
.. Days
I \C"K t>l' lURIAI, OR RI:M<'\ \1,
-?
I) ATI', il r.! -MAI. nr R i:M( )\AI,
LA^VA_/C< Ov b T QO H
rNDKKTAKllR
wmr>,mmmm^m'
IN.
B.-.Kveny Item o? Information «hould be cnrefully supplied. AHB «hou.ci «- ^V'^^^SJ'"'.!^!' ^, ,„Zm„Uon'' for
«t«te CAUSE OF DKATH in pfnin terms, thnt it may be properly cl««H.».ed. The Specol InVormnt.on for
son» dylnft away from home should be ftiven in every instance.
PHYSICIANS should
pwr-
I
'3
if
li^
â– 'r
ill'
I
I
III;
it I
I'
li
WRITE PLAINLY WITH UNFADING INK
tditssUh^^^'S^ i'- *'^lr?J^"- I'^'^i' **'•
/)((/(â– t^ilc^l ,
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
DEPARTMENT OF PUBLIC HEALTH==City and County of San Francisco
Ccvtificate ot IDeatb
( *a. S. J^'tan^ar^ )
St ^
-f m
y (0.1 -\ ^up
PLACE OF DEATH: — County ofOcm^ X^C^vvcvo.c^. City ofOcu^ 0 ^<x^-v-c^.r^<^
No.
â– \_L
St.;
^
Dist.; bet.
'^o
and
,e^'\X
■•ciiAi orciinrNrE ri«E facts cailfd for under "special information" N
( '^ ?roZrTorc^.::.v ::r.o^Z[ o^'?Ns^^"J;â– o^N^o.;rl;l name .nst.ao of stb..t ano nu.b.r. ;
FULL NAME
<x
i:
f"V;
ro^v>Aycx
1^'
t
» 1
\i \
' «
I •
ti
<1.\
]>
PERSONAL AND STATISTICAL PARTICULARS
HI Kill ^ ^
l.K.i
^â– 1
iol
H
\'.,)lth:
\X M \ k K 1 1- '
(Writ
.1<
LU -^cLt^^^^-'-^cL
HiKi'n ri, \>"i-
iStatt â– ' i'l:\
I \tiii:k
HikTiin. \' 1-;
<il" JAPIIKK
I Stat I- or i"< Ml ut 1 \-
M \i!m:x N \M1-,
t»l MdTIiJ'.K
lURlMiri.ACH
Ol' MOTUHR
fSiaU' >ir Country^
I orri'ATioN
Kr uh-J I" S,ni I' I a II I
)■.'„•;
yfniiUi.--
Am.
rin- AHovK sT\Ti;i) i'krsonai. rAR-ruM'i.AKs ARK VKvy. r«> iHi-
Hl'.ST <)I- MV KN'i)\Vl,i:i)(".K AND HI'.I.Il'.F^^
Qf>w
n
' \(i.iii'<'^
(,.^ Li
15 01 IX Jyv^o^'
It
MEDICAL CERTIFICATE OF DEATH
DATJ-: nl- Dl'.ATll
I'Mon
as
<nav^
(Ve:ir^
I II i;k I'.liV Cl'.KTIi'V, Tlial I aUcMKlod (Ucc:tsc'(l fmiii
I (p l« > ~ J 'P
that 1 la<t saw h - alive on ~ " T90 ——
aii'l that «H'ath ( iccurrccl, 011 the ilaU' ^latc(l abow. at
M. 'I'lu- CAI'M". <>!' DI'lAl'II \va< as follow'^:
(X-AXV^^^ 'J-^C-^^'V^U^ xXK\vvdL .^V-Ow4' /\L'Cva.x,aJL
nrRATloN >"'''/^^" Montin Pixvs Hours
,NED V J>V<K>
Monlhs
na\
(SIGI
Hours
M.D.
SPEfelAL Information "nly for Hftspitals, Institulions, [rdnsicnts,
or Retent Residents, and persons dying a^^ay from home.
Former or
Isual Residence
Wtten was disease rontrarted,
If not at place of death ?
Hov* lonq at
Place of Death ?
. Ddvs
ri.ACK <>I' I'.rKIALttK ki-;mm\ai.
JlocrW
^ /"D
INDIORTAKI-.R
(Adilrrs
e
Ow^w4.AAj"
xsb
i)\ri'. ■>!" liiHiAi. «.i ri:m<ivai,
WJ 0 ...
Ou^->-'
V ^'m;
y
I \\
\' A AP.F ahoiili! be stntetl liXACTLY. PHYSICIANS hHouIiI
N. li. Every Item o? m?ormntlon should be cnruVulIy HuppI.ed. AGB f "7'" ^^^V "Soecial InformHlion" for p.r-
8tate CAUSE OF DEATH in ph.in terms, thnt it m»y be properly cloBs.^.ed. The Spe.ml P
son. dyinft away from home should bo feiven in every instance.
i'.i'l
J9i^
■• f-
I
Mi
I
&
WRITE PLAIN
LY WITH UNFADING INK — THIS IS A PERMANENT RECORD
^P4iist
it?^^"^ U&i> Ca
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/>((/(' /'^/f('(/.
cL^rlA.O«i
\^Xaax:]^a^vaX XI
100 H
Jfp<j/\sfe/'cd Xo.
1248
Deputy Health Oflflcer
DEPARTMENT Ot PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of IDcatb
PLACE OF DEATH: — County ofO a->^ Oxa/^^^^^^XM)City of Uo^Tv JXa,.^x.c...<i, ^.c
No. \1^
\ Dist.;bet.U)X,-KLi
and
'vA,v.>^'Cy\X' VJAcxr^;. St.; 7 — - ., r \
V^v- w- ^-^ ,,e,,«, orQinFNCE: GIVE FACTS CALLED FOR UNDER S PEC I AL/jl N FO R M AT I O N \
( '^ rF"o7A.°^occu%r;,rrHo"s"pyT*.^ iiv.i^r.^L^r..:'.'^.\ name -.stead of street a(jd .umber. ;
FULL NAME
n
Dx
.O-A
I
^
\
PERSONAL AND STATISTICAL PARTICULARS
DA rj-: oi I'.iu in
\i .!•:
Miintlfi
1
.l5'l
'iH ,, ,
n
^ T
I \ \-.\\
Da
(Writi ill "^orifil iK«.iv.'tiati>ii '
UK I'll I'l. \«'i-. n
St:il< or « "iiiint i \ -A
A {
N\M1'. OI
!•• \iiii:k
lUR riii'i.Avi-:
OI- lArm-iR
M \ll)i:\" NAM I
<i| Mol'Hl'.K
i'.iK'i"iin,A> I
(SlaU' «ii Ooniit I \)
' " * I PAI'ION
h'f.idril ,11 Sou f'i,ui, irn Ho 'â– ""â– " !/,./////>
/i-M.
IHJ-. AHOVKSTATJ-:!) I'KR'^ONAI, J'AK'riiM' I.ARS AKi; TRl l". r«> |■"'•-
r>i:sT OI' Mv knowijcdcl; and hi; 1.11". I-'
UrMlCS-
(Vt-ar)
MEDICAL CERTIFICATE OF DEATH
DAIl-: '•! Dl-.Aril ^
I lIl'lKl^IiV Cl.kTIIA', 'iMiat I allLMuk-d iltH-cascd truni
CL.v.'CV ^-^ i^P'^ ^" LLu^ as i(,oH
that. I l.'ist saw h . alive on ^^^-^^X^ Ao tc>o i
:iiul that <kMtli nn-uircd, on tlic date stated aln-ve. at 1 1
\J M. Tlu' C.M'SK ()!• i)I:A'I"II \va< a< rnl!..\vs:
DC R A'riON'^^^^^'^^J'''^'"'" ^ Moulin
^
Pay.
I lou} :\
\x.i
DrR.A'PION
Q
) V(/^.v
<I^J;////.^
Pars
M.D.
(Signed ) OlD. o*. '\.'^\vi dix) cLxCLvv
FECIAL Information ""'v for llospit<)ls, institutions, Imnsicnts,
or Ketent Residt-nfs, dnti persons dyinj mA\ from home
Former or ""^ '<»"" '^^
Usual Residence
When was disease rontrarted,
If not at piare of deatti ?
Plare ol Oeatfi ?
Days
wi.Aci': Ol' i!rRi\i^<'R ki;m">\m.
INDI'.K
n-AKi'.R CcLa^aXWtL
(.'\(l<h<
l» \\'\'. ..r 111 KM \i. «ii Kl'.NK >\AI,
Q.
K V,0
11 ACF «lv,tilcl he stated HXACTLY. PHYSICI.ANS should
,f 1„f.,rm..t5on should h. cnrc^ully .supplied. \UT. sho, I.I '»« «*"^'^ -Socciol InformHtion" for p-r-
i OF DEATH In plain terms, that it may he properly classified. The Special
N. B. Hvcry item «>
state CAUSE . .
sons dyinft away from home should he feiven in every instance.
/ .
#>
U
\
V^'
;«■«:
!â– â– '
5^^-
ir \
i'
h
! I
T^ WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
|.lfS:^n&l'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
ino^
Bci^istci'cd Xo.
1249
f},^\A.^ Jo^.\> .( Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of £)eatb
PLACE OF DEATH: — County
I "a. S. 'I•tan^>at^ )
%
4.
No l(ilH Vllw<iyKxu-^\ya./vv St.: "^ Dist.;bet. T)C>^cLilAa; U-oXtand
iNCJ. ' '^ V v^_ w ..eiiAi orCinrNrP r.lWC facts CALLtD FOR UNDER SPECIAL INPORMATION \
( " ,7*;:T°-^i^cu%7cr,;"r„o",'pr,i^ o%'fN."?u"4'L'";"74 name ,~s.»o o. st«..t ..o ..»..,. ;
'La.aXa-V
V^La,\' )
FULL NAME
<X/T\
'XA"WCX.'\X
~!.\
i> \ 11, < ii i;iK 111
\ I . I â– ;
PERSONAL AND STATISTICAL PARTICULARS
^uixA^U..
IH , ,.
a
10
), .' '/
/^^O
lb
--I\' . !.r MA KI< II 'I
U ll)( >\\ 1. 1) « H< I)!\ < »Ka 1-. I>
W'riti' in vixi.-il ih--ii.niati<>n)
r. ! K r m • ! , \ V ■1 •:
' St.iti- or <'iinili \'
N wti-: oi
I- ATI! IK
lUK riiri.A'i-:
OF FATlii:K
.^. .... ,., (•,.,, lit- \
M \llil-.\ NAM!'.
<il M()T!IHK
IMUrill'; ^' I
Ml' M()11I!-,R
(Slate or C(j\inti \ i
i^WXX.
1 V
/\a^cX)
f\'r^i,lr,! • i< S,i>r /'niih /'''>> i oC )'''!'
- 1/,..,///- '^ /
'..â– 1
IMi: A15<)VI<: STATKI) I'KK^ONAL TA KT UT I,A KS AKi: IK 1 l' 1' > l"'"
i!i-:sr <M' M\ KN()\vi,i:i)c. K .wd iu:i,n*,i-"
(Titfoniiatil
i \.l'1lrs
MEDICAL CERTIFICATE OF DEATH
DAI"!-: ()!•■Dl'.ATll /O
(Month* A (Day) (Year)
I HlvKi.l'.\' C!;k'rn'\\ That I atlcmlrd (lt(t.a<f(l fr<>iii
NtwLu ^'l iqo3 t.) LL^XAy 'XS i(,n S
tliMtl last saw h^'^v alive (Ml LL^-^ ^- 5 i(,oH
,111(1 that .jratli orciincMl, oil tlu- date state*! above, at o.\0
\J^ M. The CAl SI{ Ol' 1>1"..\TII \\as as follows:
CONTRir.rTORV
1)1" RATION >''(ir.s-
.]/i>/;//is
Days
I lour
Mmil/i
/hjys
(SIG
(K^
Wa^^
\XiM^>
Si
J lours
M.D.
(x^a^^ .'.')H ( \,M.v-)Un 6xJlji/v Bt
SPE
dAL INFORMATION '>n!v lor Hi
or RtMpnt Rfsidcnts, .iiiil ptivons dvin;) .n'.,iv frn:n home
Hospitals Institutions, Transicnls,
Fnrmfr or
Usual Residence
When Has disease rontrac ted,
If not at plare ol death ?
HoH lonq at
Plare ol Otalh
Oa\s
I'l.ACK OI" r.r K lA F, (»u k):m"\ \i.
I ) \ ri" (I* I- !â– ' iM oi k i:M( )\' \ i.
X\
TQO
(Ad<lr« ss
isn^B-^^^xxx^ ^1
"' â– ITT Kcr k],oiI<I bo st.ited I.XACTLY. PHYSICIANS shoiird
N. B. livery item of information should be core»ully suppi.e.l. At.i. si .. "Soeciiil Inform ai.n" for pcr-
«tntc CAUSE or DtATII in plain terms, that it mny be properly claHH.^.ed. The Specnl
son« dyinft away from home HhoiiM be <iiven in every instnnce.
I'll
*i
?•*!'(
i^
\ I
^!..
I . .. â–
•i
• '~i^fl9 ' ^'
\U )
I
'i I
«
.1
':wm/
ilrefj
WRITE
PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
;: nSi\' C'l
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
J}(f/(' Filed ,
dV'Cy-^^A/v^
IfJO'i
fivc^ah OfTlcer
Bo^isld'cd J\^<).
1250
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtiticate of Bcatb
( 11. 5. 5tau^a^:^ )
^
PLACE OF DEATH: — County ofOcc^ lv<v^>-Cc^cCity ofO.C^^v J;vX^^<^.^to
N
o. H^^IX flVJ^CycL
St.; '3n Dlst.; bet.
and
\ I ^.. .iciiAl orejinFNCE GIVE FACTS CALLED FOR UNDER SPECIAL INFORMATION' \
FULL NAME
OO
-<X/vrvcL
PERSONAL AND STATISTICAL PARTICULARS
si:\
'â– '"â– " UJJ
X^OC
tx.
1 <»I III K I'll
^! .nth'
â– l);i\l
A^^x
Tl
M\ ; i M \KK n-*.i»
v\ii)t lU 1-. I) (»K i>iV( tKv i;u
iWiitriii sni-inl <h '^i'/'iiition )
I'.ik rii ri. \ri'
I Stiitf i)T r>iiiiit ; \
NAM)' 1)1-
I- All! i:k
HIRTllil.Ari-,
o!-' i'.\Tin:R
S'Mtr <r, ('oiilltl >â–
MAIDl-.N NAMI".
r. IK I' HI' LACK
•>1- Mi)T!n:R
(StaU- or C'oiiiitJ y
J .odUr-^-A>-CcL
X/y'\/'>r>U^^^V\/\^ tX'^'^^v 'CC
^y^.Jj^
^\yy\'
JL/-Y^^^/^v^oOA.yV/V<X/>x^^XX;
/\''\ l,!fi/ III "uHf /'l I. ,h / ''< I A ''' _____———
rilJ'. AliOV].: STAI'l'. I) I'KK'^ONAI, J'AK TUT I, A K s AKl, IK' i'. It » I IN'.
I'.l'.sl" OI' MV K M )\\l,i:i)( ,1<; ANI> lil'.I.n". !•â–
1', v,'//.
/i,!\:
dill"')' nianl
VJ IxaA-ajl X) ^oou
I \.!.b.
\X^l%
i
t-
MEDICAL CERTIFICATE OF DEATH
DA 11', « »1 I)1-:A Til
,M,,„tJ,) /j' (Day) (Vc-ar)
I II i;K I:i;N' Ci:R'ril W I'liit I attciulcMl ilccfascd from
Ih.-it I list saw li A- .. V alive on \^aa-\^H.. *^ "^^ i'/^"
.111(1 tliat (Kath orciirred. on llu- daU- statial above, at
UwA.^'Q '^-■'•'^
H
/'O
^ M. Thf CAISI'; OI" DI'.ATII was as follows:
vj A-yL't'Vv «- v^'i.^ crv- oJL^'v-wv<^,<<i^
I )r RATION I )'r(irs IC MiVilln Pars
CONTRIIUTORV
I lours
I )r RATION
(SIG
)'(•<? r.v
Mouth-
Pavs
/ /(Uirs
NED) H UU jJU.<r^ oJaajX^ o'^"^'
Gj^q ^n i.ll>H (A.Mivs^) â– ^HC)dxJduLN; dl
SPFCIAL Information ""'> '">â– HosplUils, institutions, Fransicnts,
or^RecenT Residents, and pprsons d\in;| dw.i) from home.
Former or
Usual Residence
When was disease tonfrarted,
If not at plare of death ?
lioH long at
Plare of Death ?
Da)s
rKAcr: (ir HruiAunk ri:m'>\ai.
lr\ ri". o! I'.riM \l. I'l K 1-.M< )\'AI.
(.\(lilrcs-
■«• iBsa m
^ ,. . »(^F. sh....I(l bo stnteil F.X AGTLY. PHYSICIANS shoultl
N. B. F.very Item o? informntion «ha,.ltl be cnrcti.Hy Huppl.c I. ^^.r. nn -Special fn»'orm»tl..n" (for pT-
8t«tc CAUSr: or DI:ATH in pli.in terms. th;.t it mi.y be pr.,pcrl> claHs.^.etl. me «,
«on« clyinjl nway from home hHouIiI bo jiiven in every instance.
im.A
-m^^f^
f
w
' t '
. 1
r \
4r
iiiis>ji
!«
WRITE P
LAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
-^&.
. -A
f^rv-
ij' lis- 1» (•
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
ii
I ^
i
t ^1
I!U)'\
ISI^l
l)(il(' Filed .
DEPARTMENT OF PUBLIC HEALTR-=City and County of San Francisco
Deputy Health Officer
Ccvtittcatc of Bcatb
^
PLACE OF DEATH: — County ofClo/^^ JkxX/>^<^^cc City oi^O^y^ 0 Axx^^v^^co
TSk).
Ch<t\wL.oul: St.;
Dist.; bet.
- and
I liicllAI orQinFNrEr.lVE facts called for under "special INFORMATION' ^
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
[fLouLfi
\x - v-v jU-
I) \ 1 1 I >i i.;k 111
10
11. .\
,lt,Hn
55
"^iNc.i,!-:. M.\Kuii:i>
\\ ii»uwKi> OK ni\t ii'v in
iWiilt ill -oriril (hsij.'niiti<)ii)
^ l/..>^'//^ L)
/',M.>
II IK . ; MM, \r l-
i Slatr 11! ' '■m lit : •>
NX Ml-. <»1
lA TH i:k
iMurii ri, \> 1-:
Ml 1 \ 111 l-.K
s| ill I ir Ci HI III I v*
M \I !>I'.N" N AMI'.
"I Moriii.; K
niRrinM,.\ci':
«>i- M()Tni:R
(Sl.'iti' or (.'.Muitty^
1 •'I'rp.xllnN
- M.'iif/.'- " /'
Tin', .MtoVJ-: ST ATI" I) ri'-. KSON.M, 1V\ K f tc C !. \ kS A K 1 '. 'I'Rri-; l< I rill'.
IU:ST ()I- MV KN«»\Vl.i:i)t'. !•: AM> lU.I.n.l''
( \.l.!i^
^
I Month)
/on H
(Year)
MEDICAL CERTIFICATE OF DEATH
DAri', 111 1)1. A I'll
lb
(Day)
I lIi;ixi:i'.N C'liR'ril'N^ riiai l atlcipU-d -U-rcasL-d from
CUaxv in. lc,oS t.. LU.\/Q "^-^ Ti,o H
that I last ^a\v li A. v\^alivr on U^A>^ 'Xio 190 H
aii.l tliat death (.criirred. «'ii the dair slatod ahovc, at O- D J
r
M. 'Phi' CM SI^Ol" Dl'ATlI \va-> as follows:
Dlk.XTloN
CONTRIIU"
)'t\7rs
Months
/hns
I loins
LLW..cKK-A-i/S-^
l\ivs
l«c i.,oH f Addtvss)
Hours
M.D.
<^ Lc Ibft^^vvC^
(SIGNED) 0 . ^ <^^'0^
LLtt^c^ I'c I.)
gp^^j^l_ Information onlv for llolpiUils, InNfifulions, Irdnsients,
or Recent Residents, ,inil persons dvinj <m.iv frmi home.
Former or ^'^ t -l \ \
Isudi Residence O J.D O .<,A.\.A^tnrv
When was disease rontrafted,
II not at place ol death ?
o
Davs
iM M')-" 01' r.rKi.xi, OK KiiM' >^M.
i).\ ri: -it r.i 1' i.\i oi k i;m( iwai.
(Addi
^ T^, .p.- «u„,,|.i be stiiteil FiXACTLY. PHYvSICIANS should
!N. B. r.very item oV inform.ition «houlH be cr.rotully suppl.ecl. ^^"^ . i..K«ir.ecl Th" "Special Information" for p-r-
state CAUSE OF DIIATH in plain terms, thnt it mny be properly cU.Hs.t.eti.
«ons clyinft nwny from home should be ftivcn in every mstnnce.
m
t-:
I.
^.
4'.i*ii
'â– S
I
i I )
ill
I
i
li
!
« I
1 1
1
^
WRITE PLAINLY WITH UN
N ) (. : N
•^-Z"*"w
UB. H <*rt
FADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/ht/i' Filed ,
ai
li)0\
jRsiilstei'od jYo.
X's^O^
ou^ 'kjOxMj^ Deputy Health Officer
6\Ji/\XA
DEPARTMENT OFTUBLIC HEALTH=City and County of San Francisco
Ccvtificate ot ©catb
Xl. S. 5tnnDarc> )
PLACE OF DEATH:-County ofOo/^v 0 ,V^^cv^^.c City of O /C^-r^ 0 ^v^x^^^^^^
No.
:^
v^<l U AX'^ vCV- V, c\ uSt.T> >
cl
Dist.; bet.
-and
( " rr;;rH"occ^%ro\"rHo^s^"*t o%'f^?n?J;^o';"o.vc .ts name .nst..o o. st^.^t ..o ^u.o... ;
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
"^^- QSp
• \ ! 1 < i|- I:!K 111
1 ' i!.' 'K \
vJjJv^JL^
^.
(Day I
I! I
\' .I-:
Ha
! V,;
iiiu riii'i,.\ri-.
Stiitf or Country
11 LO^VX,VwK.C^
/).n
VAMl. < il
I" AT 1 1 IK
nik in I'l, \ri-:
< >i 1 \ rii i-,K
M \II>)-:N N AM)',
nl MoTHHK
iiiKriiri. \t 1-:
'•1 motiii:k
J.kXxj^'''~>
III I I
i\lI*»N (j\
Rfsitlfi! in SiiH /'i mil i-i'i) ),,;/
- yr.'ittii^
Ihiv
111 \I',..VK ST\ri.I> l'KK>.<)\Al. I'XKI-Frri.AKS AK1-. TKrK T. > TIIJ-
r.l-sT oi \\\ KNOW l,i:i)C.H AM) lU', I.Il'.I^
(Acldn■.^ ISSL U)xJUtiL>v ^ Cll^»^-^^-^^
,. ■.(.p «,,„^,|il be HtHte.l fiKACTLY. PHYSICIANS «houlcl
N. B. Rvery Item of informntion .hould be ctiroVuMy Hupplicu. . • ^.,„_„;f5ed. The "Speclnl Informiitian" for p«r-
«tBte CAUSE OF DEATH In pinin terms, that It mny be properly cl»«H.V.ecI.
son, dylnft away from home should be ftiven in every instance.
MEDICAL CERTIFICATE OF DEATH
\)\\'\- <>l ni.ATM
a>
(Vf.'ir)
'Mont 10 h ''>-''V^
tliMtllMstiinvli^^'v; alive- OM LU^ 'XI up\
.â– m<l that .Kalh o. rurrt-.l, ..11 llu> .latr ^tak-d ahnvi-, at 'i-H-S
Q M. Tlu' CAISI-. 01" Dl'-Alll was as follows:
LL'V^^XX-J^'i-^ 1 v-v.<^. '.- ^''
DlkATloN y''^i-S
Months Pais H Si I louts
^' ' • ^.LuvX^l-<rv%
C()NTl<iI!r'i()I<V ^\:'<^^â–
(SIGNED) J JU\JlAA.4aM'l Ia. .^^^
Hours
M.D.
o.n
I()0
H ( A.Mi-r^s) bOb Qa^Ix^^v 3/1
SPEJJCIAL information "nly lor Hflspitdls, institutions, rp.jnslents,
or Recent Residents, dnd persons dying dWdv Iro.n fiome.
How lonq at .
X PId'e of Dedlh? o Days
Former or -d
Usual Residence U Ou'
When was disease ronfrarted,
If not at place of death ?
U
X^^aaAJA
.^kK\.
I'l.ACH Ol' lUKFAI, (tK kl-;Mt>\AI,
I) \! 1: ot III IM \I. nl U IvM* »\' \I,
TQOH
/P^
n
63
/
I (
H
M«S
« ;
fUT!
Ml
I.
i
h
1 1
I'
li
"I
I'
w
RITE PLAINLY WITH UNFADING INK
f-*^"***?
in r .^'
Dfffc nii'd ,
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
an
liJO'i
Hcilisfrred J\^o.
1253
Deputy Health Officer
DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco
Ccvtiticatc of IDeatb
^ 11. j5. StanDavD )
ofj CL^^ 0 K<X/y'K.^:AA^ City of ^ ^^^"^ ^ .V<X'->-vc.a.<l ^,c
PLACE OF DEATH: — County
N
o.^H5
4
\)
and
L^<i-"^V-'(r>-\..' RrSlDENCEG.vr FACTS^CA^LtD FOR UNDER "SPECAL . N TO R M ATI O N • ' \
AWAY FROM USUAL RESIDENCt-Givj FAt.1^^ NAME instead of street and number. J
h'X.'
( IF death occurs away from U3UML. "'-^â– "-â– ', - ^ _,^p
\ IF death occurred in a hospital or institution give
FULL NAME
I \ i I. • »i- r.iK I'll
\' 1'.
PERSONAL AND STATISTICAL PARTICULARS
j C<»l,tiK
\
"IS
X
« I):ivi
!• -•■/.
â– >'t ar'
'X5 Da
^IN'.l.i:. MAKkll'.D
WlKnW'KI) OK l)IVnKri-:i)
Wt il' in sociiil fl.-.i'-" <i :"ii '
KIK llIl'hAi'J-;
(St;itf or I'oiiiit I >
,JodL<r-v\>X/<^
^xi_v„cLj-^^
MEDICAL CERTIFICATE OF DEATH
DA ri-: ' »!• ni-.A Til
3.(0
(Day)
igo'\
(Year)
I Month) A
I III'.RI'r.V Cl'RTll-V. Tli.it I altcii'lrM .U-ceasc'd from
\ WW. Dl-
I \iim:r
I'.IK IIIIM, All".
<>i- i\iiii;k
' SI. lie nl Coniltl \')
M MIU'.N N AMI",
<ti Mo'nii'.k
I'.iui'iiri.Aii",
'II MOTHlvU
'â– '-tiitc nr t."<)nntt y)
' •* ( I I'A THIN
fy'fiifrif III S.ltl /'l illh ixil )i-tJI.^
^r•nlh<
/hn.
Till
flnf.,:
• Minvi.-. SI-ATl.I) I'l.-KsoNM, )■\ R I" UT I.AKS A K i: T K T H T' ) THH
;!i:si' <)!• ^\\ KNoUl.l-.iX.l-: .\M» lii".!. 1 1" »'
— lip to "~~ "
that I !:i>-t saw li " alive on
;,ncl tliat .K-alli (.crurrcl. on tlif date statcil alx.vc-. al
M. Thf CAISI-; ()!• I)i:.\ril was as follows
I(>0
T()0
CONTRHU'I'ORV
Mont/is
/hns
//ours
I )r RAT ION
(SIGNED)
(W
}'<ins
Hours
XsXol/>vxL UiUvv^lN- M.D.
SPEcllAL INFORMATION only for flospit..ls, InslifuthiAs, Irdnsients,
or Recent Residents, and persons dvini .iw.iy frnni home,
r „, Hov* lonq .it
Usual Residence
When was disease ronfrarfed.
If not at place of death ?
T90
,., ACKor HIKIAL..K KHM'AAl. LU"...., HnoM. -i Kl-MoVAI.
hire... H0% \5 0^^>UJL t^t^-
(Atlt
' ,. , 77^ «Hould be stHted KXACTLY. PHYSICIANS Hhould
N. H. i.very item of nWorniHtlon should I,, cnrefully Huppi.ed. 'y^ cla«».1f5ed. The "Special lnform»tion" for pT-
stHte CAUSE OF DEATH In plnin tcr.n«, that It may he P' '>P«'"y
sons dyinft nwny from home should he ftiven .n every .nntiince.
i -J. i.
t
r^^
r:
I
!â– !
li
I !
I
J.
iff
W
RITE PLAINLY WITH UNFADING INK
THIS IS A PERMANENT RECORD
);,,,,;,! i ifrrrTtlT—
_>v HS.- P Crt
REFER
TO BACK OF CERTIFICATE FOR INSTRUCTIONS
1 )((!(• hllrtL
X\
io(n
]lr(:i.s{ci'C(l JS^o,
1 254
^ Deputy Health Officer
DEPARTMENT # PUBLIC HEALTH-City and County of San Francisco
Ccvtiticatc of IDcatb
N«. v^ttn'^
iSl.'itt.' or Conutry*
I 11. S, jT'tanC^ai^ )
PLACE OF DEATH:-County of Oct>. i/VC^^^^ City oi^^^ 0 AXX^^c^o.
Jv^l/^-^A., l^b CV<s j^^-l- a '■St.;— -4)ist.i bet. ' ^^^ .
-â– )
PERSONAL AND STATISTICAL PARTICULARS
FULL NAME hTWv^ 'd)XKA>^^^
â– J Xy^rv^^o. 'v,^.
col, OK \ ^
ill urn
Dnv'
â– V. .ir)
:i5
- , ^. .,,; MARK 11. 1).
W ll>(>\\ l-:i) OR DiVOKCi:!)
MEDICAL CERTIFICATE OF DEATH
l»Al"i: < il IiT.A Til
as
190 '\
Month » A <r>-''y> '^'^•='''
I lii:Ri-;r.V C!;RTI1-V, That I attcndc<l dercascd fr-.m
TTT-
TTT
I(p
\ \M1 . >!
I A'i'il IK
I'.iK rniM.ACH
Mr ! \r!n:K
MMDKN' N^Mi:
«>l- Mn'nil-K
i'.:u nii'i.Ari.:
'<! MoTHKR
^1 • ■I'l.iintiy^
'"'"^ %
i 0
■!!V: \H<.VK S-1-\T1-I) PKK-oVM. )• \ K T U" f I . A K ^ AKl'. TliVr. Tn T H !•
I'.I.sToi- MV KN( i\\ l,i:i)C. }•; AND Hi'.l.Il-.l'
: iiiMtit
^K^r^^mmmn^mm^'ir^^
that T last saw h alive on ^9°
and thai .Kalli occurrcl. mi the (h.tr <tatc-.l alx.ve. at
- M. Tlic CArSl". or DI-ATll wa^ as follow^:
V
(I
CUi-
iJLy<L,<:,A_dLji/VNZtxtxX C>-/tYvvAltA.xr>-
LONTRlI'.rToRV
Monl/is
/hivs
IIOll) ^
M,)>il/is
/hns
DTRATION '' '-'-^ 1/-)^////^ /"o.^ //'^//'v
SIGNED ) Ur\xi^^4>v 1 ' i3. UllxW M.D.
(-v-cJL
SPECIAL INFORMATION oniv lor Hosj)itdls InstitiiHons, Transients,
or Recent Residents, and persons dvinj dVN.)> troin home.
\^lien was disease rontrarfed,
If not at place of death ? ^
Davs
l-l^CK Oi HlKIAl. <.K KKM-VAL I I'AT. U'u.u ,„ KI.MoVM.
^^(l(hr^'
•' ' "* TT T-F s'iov.1.1 be statea f.XACTLY. P1IYSICI\NS hIiouI.!
IN. IS. Kvery item of niformntlon hHouI.I be o.rct'ully suppl.-Ml. ^^ ' . .|„„„inetl. The •'Special Inform if.on" for p«r-
«tatc CAUSE or DLATH in plain terms, that it may h. properI>
. - « . 1 1,1 K.. rt:v#.n in every instance.
state CAUSE OP DLA I M m piam ierm«, »..".
sons dyin4 away from home should be feivcn m every instance.
!i
j
<♦».
I •>
I
) u
â–
I
. V!
i
'^^â– n
I i
I
I-
«***'^
**
«r
in
II
li
ii
!•!
i i
Hi
'• .
' «
H
ri
^'i^
WRITE PLAINLY WITH UN
FADING INK — THIS IS A PERMANENT RECORD
d '•^•^
ITTinn:
r:^^^i:]\Sc\'Cn
REFER
TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I /)(//(' Filrd,
'r\
ltl()\
Beili^'<f('rc(l Xo.
1255
Deputy Hcwai^r
DEPARTMENT OFPDBLIC HEALTH=City and County of San Francisco
Gcvtificatc of Bcatb
PLACE OF
i-^
No. ^>^>
^1
DEATH:-County ofOcu^ 0,>v<Xy>^c^^Gty of U,<XAV OXO^vv-^^ '-- c
r\ r\ . /-.aVI' St.: Dist.;bet. - ,
?t^:^.,. .w.v .no» USUAL R5-.?5^a^-".^:;74 =.am" .'."A- " sT.^.^riJo '^1"'.°- )
(■r nrATiM OCCURS ti\N t^^ FRONI VJOw»^i. . !•---'■>--■•
Tr Dtt" O^^^""^^ "- * HOSP.TAL OR .NST.TUT.ON GIVE
FULL NAME
0
x^vvwC 0 CrVLCvv.
~! \
PERSONAL AND STATISTICAL PARTICULARS
I COI.nK^
1 i'.lKlll
d ^^-^ •
M .!lth !
51
^
1/ .K.//
«-i\t .1.1- M \KK n.i>
St:tt«- or Ci)unlr\
MEDICAL CERTIFICATE OF DEATH
DA 11-: <u ni:\ Til ,0
Vjo-A.'
Month'! j
.A l". ujoS to vLc^O^ ^Xlo
w on ^^
U)oH
'Ixxvv^^-rL
\ \M 1 t >;
HiKTiiri.Ari-:
«>i" 1 \riii-R
M \ IIil-N NAM}.
'I! Morin: k
I'.IR rill'UAt )•:
or MOTlll-'.K
V-3
V^
^^z
RfM'i!r:f hi Siiv I'laini'srit 051 ' ' â– '
m: Ai'.ovi-: sT\ri;n i-kk^oxai. r\K ti'Ti. \k> aui'. rRi}-. p. riii'.
I'.HST Ol- MY KNOW l.l.IX.l". AM) lU.l.Il.!-
' Inf<i!iiinnt
r\d(lress
^,„.l tl,at ^Uath ..(rwMol. on tlu-lal.-tatr-l abnvr. a1
<)\vs :
..V/5
,,, RATION i )-,^/X^-y""^^'' ^'''^ ^^"'"
CoN'IKlHtroRV
loLOi^L-^vxxX L^rvA^tX-'CiL'w* V V,
DIRATION
) Vjr.s"
V^
Mi^uths ^ Ptivs Hours
SIGNED ) M 'ULLLoL/>^. '-X^,>c\^ ^ ^ M.D.
" SPEcJaL information "nly for llospitdls, Instilutions. lr..nsi.'nls.
or Retenl Residents, and persons dving HH,iy fron hnme.
Former or
I'sudI Residence
When was disease rontrarted,
If not at place of death ?
HoH lonq at
Plare of Death ?
. Dav*
iM,ACi-: oi- m-RiAi-cK ui;m«>\\i.
1 1 \ !1 . ,; !',! M I \i t'l 1< I'.M' »\ A I,
i 1
Lv^^A,
zh!w^o.AA^^'^4^''-^^
^
r,x,i.h-.- nil mYLa^^-xl^-cax ^1
T90 \
\jUyvv
"- " r— — " r\ TpF «h n.ld be stated EXACTLY. PHYSICIANS should
N. B.— F.very item «V' inf.rmntion should h. o.ret'ully «uppl.ed. '; ' ; ^.^^^..^iecl. The "Spcciol InforniMlion" »«r p.r-
«tatc CAUSr Of DEATH !n plnln terms, that .t may ^^^ J*^^''^
r.on» dyinft oway ?rom home Hliould he given .n every .nHtonce.
'^'^^'^
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.1
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RITE PLAINLY WITH UNFADING INK
; .4 llfultii' K No. T. "*^^i^ 1»&H Co
I idle Filc'l ,
IUO'\
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I ^â– â– nBr^ww
DEPARTMENT 0?PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
PLACE OF DEATH:-Coun,y ofCcmv J ;^..v^.^<^ City of O^C^ Jxcc^vvc^
<^t'
N
o. Hi Lljyl\-cL"v"vjUA
J ^^ , , ^.. , , . St.; I 0 Dist.; bet. Ux^VcJi '. and 0 <X >^U^ \ )
J A\^^<\j^ KJU^\ ^ro.ArMrr riur facts called rOR under "special INFORMATION' ^
ALLED FOR UNDER SPECIAL INFOHMAIiui
lAME INSTEAD OF STREET AND NUMBER.
FULL NAME
,^"i'^ \X^
^^x o.
<^^
PERSONAL AND STATISTICAL PARTICULARS
C«il.' iK \
II
Lv. VvCtx.
1
11
1,1 M \ !•• I- 1 1
r.iK 1 lll'l, \»*l"
'Stiitf or ("•iinit : \
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<>l M» II" 1 1 1 K
lilk I'M I'l, \r i:
n\ M(.rni",u
' '^i I ' 1 1 ". .\i 111 I
1
X
MEDICAL CERTIFICATE OF DEATH
, |i|,|. |.i;\ . I Kill V. TImI ! inrii.lr.l ,lc-..;i.c.l ri..m
/ iV > .
v^L\.\UT. ^ '-'
,),:., ll;,s't.,ush >l--'n LL-C^ ^^'^ 1<P'
;,,„lll,;.t ,l.-,,l!l.HrMM<.l. .•■! tlu-lMt.-t;.1r.l aliovr. :.t
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J A^U-L^CXAX^Mi.^^ -J ' '
^^'
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lSi:ST nl' MV KNt>\Vl,i:i)' . 1 •. 1 » I'.l 1,11,1
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DIK.XIION
)V(/r.s"
LU JC4/<rvo
Mo)itlis
3J <X"> "
/'<n s
ICVAL INFC
{
o
^o.
M.D.
( SIGI
LIa- - ..^ ^ .
SPECIAL INFORMATION "nU tnr llospilHls. Inslituli....s. Ir..nvirnls.
or Rrrcnl Rcsi.lrnls, .inil persons (him .lv^..^ ii..;n li"mr.
formrr or
lsu.il RpsidcntP
Wlipn wds disp.ivf (ontrd(fpd,
|( nol .il platr nl (le.ith ?
tlitw lonq .it
I'j.i.c ol Ocilh
()<iss
,.,,.X(I': <•} lU KIAI, OK H1-M<'\M.
1 \ X'V. <p!' I'.l I' I \l. Ill K I .M< i\ \ I,
I f)0',
)Kj
r:'
^ + " TT MIV, HW.UI be HtMte.l f.XACTKY. PMYS.CI ANS .h.n.hl
N K._,;very item oV nn'o.,«..t Ion nhouM h- carofuMy s.ppl.- • ^ ^ ,,„«H5,'iccl. The '•Spccl..! I,n-.>nn,.t .on ^.r p-r-
HtuU CAlISr. or OLATM In in terms, thnt .. nu.y ^ P^^;^^
sons clymft ..way from home KhooUl be ftWcn .n every -nHtnn.
1 . ^'
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WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
RFPER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
•vtf&lM
â– n-^BMaiai
JlJO'i
Jl('o'/\sfe/r(l J\^o,
1257
DEPARTMENT OF PUBLIC liEALTtl=City and County of San Francisco
No.
Ccvtificatc of IDcatb
( 111. Hi. tritnii^avD ! #.
PLACE OF DEATH: — County ofCjCL^- 0>^<X^\x^4c.c City of Cj<X/>\' 0 .\X>. \a^c.<xuC^
15 ll \1X^^':^^->-- St.; 1 Dist.;bet. cLc^^Kv/>-v. and ^ Cri^k
/ i DTATH OCCURS AWAY TROM USUAL R E S I D E N C E G I V F FACTS CALLED FOR UNDER •'SPECIAL INFORMATION" \
( I .F De'ItH OCcJrRFD InThOSP.TAL or INST.TUT.ON give its name instead OF STREET AND NU^.BER. J
FULL NAME
.t
^
KAX.^\J vj
O^CJL^^JChj
PERSONAL AND STATISTICAL PARTICULARS
^lA
:>A 11. <ii i!ik in
r< >i t »k
Month
1 1,.'.
S\
Iht 1
! ' l.i MAR km: I)
Will. »\\ i-;i» OK i)i\'< (Rvi:!)
\\')it< in vi,,i:il il(sii> t',,it ii 111 '
l!Ik''"mM \i-)-
(st,-
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â– r r. mil! : \' '
MMIU-.N N\M}-:
Ol- MOTMI-.K
I'.iKriiiM. All-;
<M- M<iriii:R
MEDICAL CERTIFICATE OF DEATH
DAI"!-; »)1- Dl.ATH
(I):iv) (YfMr)
I'Mojitli^ K
I lII'lRivr.N' Clvk'ril-'\'. That I attcii.Ud (Iccvascd fmiii
at
190 ^
\% \()0\ to
that I last saw li â– "^ alive- on vX^^VrCV ^t 190 v
ami that .kath occurrctl. on the date ^^tatcMl above, at '• vO
J M. The CAISI- Ol' i>i:.\TII was as follows:
VlVx^i^<,v^JL<:L 0 .caJlmxX vlAJUXr-%v<x^'^vA^M
1)1 RATION Yearn
CoNTkllU'ToRV
1
Months H Dayy
1 1 our
^rr\^
»JL-^-
JvD 0-a-«-^.Xa,<^y*-
h'r^,,h-J
) r,:, <
■rm, \nn\ 1-. s 1' \ii-i) I'l'Rsox \!. rAK'iuri \Ks ARi; rkii-: 'r* » in i-
Illlsrol' MS' KNOW 1,1: IX". K AND ni'.l.Il.l-
'Inf.i' niiit
a.c.iju
/O.
r> v,c ' V.'
nr RAT I ox
(Signed )
) V(/;'5
Q.livW
Mn}iths
IAa.^Q lie i9o\ (A<l.lress) l^ l^
Pays Hours
-M.D.
./^Aa.^-
Special Information «"'> for Hospitals, institutions, Transients,
or Rfcenf Residents, and persons dyintj away from home.
Former or (9 I "M ^ n f i ""^ '''"'' ^* t
I'siial Residence^ CLC'M^'*^ 0 M5V-^ UV-t' pjare of Oeatti ? 1
Wlien was disease contracted,
If not at place of death?
Davs
ri.ACH (11- lURIAl, OR KI'IMOVAI,
I>Ari:o!' HrioAi. or Rl^MoX'AI,
(Address XW^b M iXv^^u-V^Xrvv 0%
N. ».— r.vcry Item o? information should b. cn^cVnlly supplie.l. A(^F. simuld be stated EXACTLY. PHYSiaANS should
state CAIISII or DEATH in plain terms, that it may b.- properly closs.lficd. The * Special InVormat.on ?or p«r-
Rons dyinji away Ifrom homo should be feiven in every instnacCt
â– sM
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WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
'•• ■-y: lli. 115; IT
/)(///' I'^i/cd ,
^M.A.A^
XI
lUO^
ItcgLstei'cd J\^o.
1 258
u Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate ot iDcath
' W. ill. t^1tnn^av^ j
PLACE OF DEATH: — County ofC)/(X->. v 0.\.OU-yxC^^^XoCity of O/O/vu 0 AXt'-rvd-O.Cc
St-).
Dlst.; bet.
and
(IF DfATH OCCURS AWAV f R O M USUAL R E S I D E N C E G I V E FACTS CALLED TOR UNDER "SPECIAL INFORMATION" "\
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
si;x
PERSONAL AND STATISTICAL PARTICULARS
cm.iiK \
J
ft' rv
.o^ \
.L.vvOvl^,
)â– ,:,,
^
[):i\ i
Moilh
1 i;ir
Ha
MEDICAL CERTIFICATE OF DEATH
vX^^A^n lie
iMoiithl K (I):iy)
I Ill'KI'IiV c;i-;rTII-V, That [ attcii.K'.l (Icccasc-il lioiu
IQO \
(Vc;ii I
^:"' 1.1 MAKIvDIi
w ii'i '\yi-;i» OK Divi >Kr}-:j)
Write in mx-jal tl( -.ii'iMt i'Hi I
.'L^'X^Q/^-
1 >'n! IK
"I" Mi>TIIKK
HIK THIM.NCJ.
••I- Morill-.K
•Si;itt ur r'luiitrvt
e
UjO ti 1 — — — — — —
that I last saw h ■— aHvc <»ii ^ —
ami that diMth nccurred, nii tlu- <lat».- stali<l ahovi', at
M. The CMS!-; Ol" l)i:.\TM was as follow^
1
^90
190
I
. ^r (/b.-v|A>JL^./tXJL^vrvx^cv oi- Xc>c%vtY3.AjL\X\hV0
'' "" " Days Hours
A
1 1 Lccv^tx
nr RAT I ON Yi-ays
c•o^■TUlIU•ToR^
Months
DIR.XTIOX Yrars Mo}iths
Hav
CX'
vl)
1
<^^ \yVvJULCr\_ CL
t.
SIGNED ^ UAX-^^JiA;
.U.A
L\xu:^ X'; T()o'\ (A<liln-<^)
//ours
M.D.
'AjUUi
:V<iX
)v-,MA- o lAu////- r [ /
rni. M'.(»\-K s|-\-i-Mi I'KK^. i\AI. l'\K I ini. \ks \ r i-; TKI
lil.M '»' ^1V KXuU lj.:i),,H AND lilvlj].!-
1: i"" 1 III)'
SPE6^AL Information only for Hospitals, Institikihns, Tmnsicnts,
or Recent Residents, and persons dvinq awav from fiome.
®? \ ■\, Hew long at
Former or ic*-t( 1 \ \4.
Usual Residence 1 o 1 b 0 a.cV4v J A pi^re of Death ?
When was disease contracted,
If not at place of death ?
(? . â– ^
ri.ACi-: Ol- lURiAi, OR ki;m(>\ai.
»\Ti;<i; I'.i i;i.\i. 01 K ]•;,%!< i\' A I,
0
T90 \
^' ^- T^.very item of iriformiition shouM be cureuilly supplied. AGB should be stated HX4CTLY. PHYSICIANS should
state CAUSE OF DHATH in pinin terms, that it may be properly elassified. The "Special Infonmition" for per-
sons dyinji away from home should be j^iven in every instance.
f1 i V
t '
\\
A i
II
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WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I No. 15 ■^•T:?!L.^ ">^ !• Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I
I
Ii)()^
Ji('gi\stered jYo.
1 259 '
Xlrvcv^ Xbv<^ Deputy Health OfTlcer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtiticatc of IDcatb
PLACE OF DEATH: — County ofO,<X'-irvO,vuX/\xi:^u^<^ City of 0,0.^10^0 yVcxy^VOi^cc
No.
k\
CrvCL/W VJ /OJ\JP,
S*.; '^ Dist.jbet. l,^\d,' and c^/vd,
(\r DEATH OCCURS AW«V FPOM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
lW
ft
\^1\^-
/Cl^wx-Aj-V C cu
PERSONAL AND STATISTICAL PARTICULARS
.0^
"1 HIK 111
L
iiii.'iR ^
UClvL
MEDICAL CERTIFICATE OF DEATH
I)A1"K « »!■in: ATH
a
\' â– ]'.
•i;
'i'V
JX IQO \
'I):iv) (Ve:ir)
5^
an
â– rvr. r.j- M \iv i< ii.-i,
• ' ' VORiKI)
-iv ii.il ii (ii)
SI;il
N'AMI-: <)|-
i;i iv ; i i ri.Ai i-;
"1 1 \rjiHk
ola/J(j vjj OlOItl
t^a.
o^
X^LA^
^!Ali>J:\ VAMl- /»
"I- M(»riii.:K ((ji)
"i'
iiikTiin. xri-
<'l- MniHIvK
' " ''^I'A ri« t\
AXX/^^^Jl
I IliiK i:i'.V C i;KTIi'N'. That I atteiidcl .k-nascd frniii
!(/) ti) — —————— —I(p
1 hat I la^t s;i\v li ah\ c on TQO
aiiil that ik-ath (iccurred, "H the (laic stated above, at
M. The CAISI-; Ol- I)I';.\'l"n \va<; as follows:
DC RATION Ycius Moiilhs Days I lours
Co.NTKir.rTORV
\A/w\AAA.A^/Oo
/\'f iliuf III S,ni I'l ,1 II, I ,1)
),-,ll ^
Mniiflf
I)rR\ri')N )'tiirs Mouths Pays Hours
(Signed ) Wur\xiL>v J. yj-UJ-dJll/cx/vu^ M.D.
X\ if)o H ( Addn'sv;) Wun^JAlA Ui VL<a
Special information only for Hospitdls, IfiNtitirtibns, Transients,
or Recent Residents, and persons dyiny dnay from home.
Hi: \tu)\i.: si'A ri:i> i'Ki<sn\ \i. i-au nrr i. xus .\ki-; tkii-: to thi':
'•i."^r Ol' Mv k.nowm; I )(,!.: AND i!i:i,ii:i-
(Inf.,-
Former or
Usual Residence
Wtien Has disease contracted,
If not at place of death ?
lloH long at
Place of Death?
Days
im_,.u:k oi' m'KiAi, <»k ki:mo\.'.i.
%
Zv
i)Ari:<)f MtKiAf. or ki;mo\ai,
(Address KX^'K^ ^^[\\jO<KkjX Of
'S. li..
A.
-Jivcpy item o? infopm»tion shoulil hi: cnrefully Hupplietl. AGR should be stated RX4CTLY. PHYSICIANS should
stiitc CAUSE OF DEATH in plain terms, that it may he properly classified. The "Special Iniformation" for p«r-
8on« dyin^ away from home should be j^iven in a\^ry instance.
i' s
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WRITE PLAINLY WITH UNFADING INK
^"'^v-
WlkVCi}
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/h//r hailed ,
o\^
al
l!)()\
Regislcred J\^().
1 200
No.
v-M. Depuiy r\A^ic.'.\\\ Officer
DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco
Certificate of Beath
PLACE OF DEATH: — County ofO-Cu^^ J , VO-'^vc^^^^^^ City of Cj/Oy^v \^ K,<Xy->i^^^^A^^t
0 I LcL.tut-^X'VV^ n. St.; % Dist.; bet. U,^cXcL/V-\-<X; and L
:ATi/. OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
(
IF OEi
I F
EkTM OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER.
FULL NAME W
PERSONAL AND STATISTICAL PARTICULARS
' -v
.OJu^t^^
A^J
v( »!,< )k
^
l\(v.,tc
(I).'(V)
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i lar'
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1' in •.o'-i;i! iIi-vi'MKit inn )
IU!.'-^-|!!M \r I-
•It ; \
1 \ 1
'■•'.1 111 I'l. \ri.-
' • I \ III |-k
<" Mt»Tlti.:K
HlUi'in-j \( i-
•»i- .m<>tiii;k
'St:Ur ..! Cuiinll \
MEDICAL CERTIFICATE OF DEATH
It ATI-: ol DI'. \i'll
(L
(I)av) fVc-ar)
'M(.iith) t
\ Ili;Ki';r.\' Cl-; RTII'W 'rimt I altcndcl (Icrc-ascd from
VOL/W' ri l^'l'l i4ja to LLuA^ Q^Id 190H
tliat I Ia>t saw li XNj alive oil LAXaX3 '^^'- Kp "l
and thatdcatli ocrurrcd, on tlu-datr statrd aliovc, at o
VX M. Thf CAISI-: Ol- I)i:A'riI was as follows:
Vy
<^
I ] . I â– I
\ rioN
(J X^y^^^Oo^'VM
1
T>
fsf^iiirif ill Sdv I'l ini, : -i-.i C) 0 )â– 'â– <.â– ' ^ "^ M.'iitli-
l>r\.
1)1 RA'IdON )'i'(jrs J/on/Zis i /^'U'-^ Iloitta
"ONTR Mil TORY jJ/woJj-O^ M I buLtAXcc-iV
Dl' RATION Years Months Pays Hours
(SIGNED ) VI fUVu^ fc^h^jy^^^ M.D.
XI T()oH (Address) %0l ' "O-vOXa^ 01
SPEuIAL Information onlv tor Hospitals, Instituflons, Transients,
or Recent RcMdenls, and persons dying away from home.
'III!"-,
1 MtDXl-: ST \ ITD I'KKSMX \i. )• \i< in II.Ak^ Akl-, 1" K T }•; T* » TH)".
I'-l-.^r 01. v|V KNOW i.i;i)(-, |.; AND in- I.Ii: I-
i'"- i',l:int
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How lonq at
Place of Death ?
Days
L'l.ACi-: 01' HrKiAi,j)R k1';mi>\ai,
DA/i^lCnf HiKlAi. or KI<;^t<)\â– A^
Xb 1 90'!
M yVv4A-A.-<r>^
N. 15.— livery item o9 mt'ormatlon hHouIH be carefully supplied. AGE shm.lcl be stated f.XACTLY. PHYSICIANS should
state CAlISn OF DEATH in plain terms, that it may be properly classiltied. The ' Special Information ?or per-
sons dyin^ away from home should be given in every instance.
'^
i ,
1 !
|:
i.!\
iMr
t\-
ll
ti'
m
,â– â– ,, I
I'-
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dale Fih'il ,
v^X 'Xc)
D
IU()\
o^
llvilisfcrcd .N^o,
12()I
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
11. S. Stan^arD )
PLACE OF DEATH: — Cou
nty of^ CL ^^' J ,^L<X ^ vc^^ coCity of 0 <X/Vu 0 yV<X-wc.A„AL<:^c
N<). LviL X
Cy<L
kJ
vO.,
St.: -
Dist.; bet.
and
\ ( IF DEATH OCcflPS AW»V FfOM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' ' ^
' V IF DEATH oQcuRHfD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
. \\M^''Y\.<:XJk)
'y^ â– ) vCr
PERSONAL AND STATISTICAL PARTICULARS
V I ti,< >k
'^IcvL
'd^'
M !;th ' jf
Ii,.\'
Ha
1
MEDICAL CERTIFICATE OF DEATH
' • X K- K 1 I ! I
\\^
iiri. vri-
I t
i \rin-R
\T!IHK
"1 MoTHI'-.k
iiiu I HIM. \i ]■•
•'I MoTlIKK
'â– ^tali- or ('..iiiitiv
in.iv)
/C^r> ^\
I iii:kl.l'.\' c. I.I-'.'1"II\', 'I'hat I attfii(k>l (lc( lascd from
Lw^<:U '-^'-^ J^P'* to \X^LA.X\^ XI i()0 H
<:^ -lu 190M to ... . LLcA^xx.
(1 0 ",, . ,,
that I last saw h -v.', alufoii V,Va^a.x^ J. , jcp ">
1 that (k-atli orciirrcil, on tlic ilalr stated above, at i • "O 0
am
V.L M. The CAkSh: Ol" DIvATil was as follows
^wCL'T^ vXC
A
'-\
I)rR.\TinN )',ais
coN'ruir.rToRV
Months
Paxs
Hours
Mo)tths
'â– 111
4\
.w/ /;,//;
.•; > — 1.'" .;//// -
DIR.XTION )Vr/;-.v
f SIGNED) 0. U\. fc<X\l.^
I\u.<
K.
Ad.hv
I Ion IS
M.D.
N only for Hispitals, Institutions, Transients,
i H1-: Anoxi-: s,'r \ iid i-kr-^' >\a i. i-ARrirn, \ks aki: iki i: r<> riii-;
'•'.-I'oi- Mv K\i )\\ i,i.;i)C. J.; AND lU'.I.n;!-
\<l.ll,ss
N. U..
^^VwC . (Jb 0-^^aX<X,L
SPECIAL INFORMATIO
or Retfnt Residents, and persons dvin;] away from fiome.
f ormer or ^ „ S^ J 4, "«>* lonq at
I'snal Residence i -jM 0 O^^Ou^rvvv CTf Plare of Pedth ?
Wtirn was disease contrarted,
It not at place of deatfi ?
Days
I'l \CH Ol" niKiAi, ok ri;m(>v.\i.
D.XI'i: oi" liiKiAl. or r}-:movai,
a"i T90S
(Ad(lic><s
Jon shouhl he carefully supplied. AGIi sMoulcl bo state.) EXACTLY PMYSICL4NS «hould
'H in pL.in terms, thnt it m:.y be pr<iperly classified. The -Spec.ol Intormat.on Vor p«r-
-Kvery item of inforniiit
state CAUSE OF DHATH
son* dyinfe uway from home should he jiiven in every instance
"^
.: ;.*
: \
^â– \
l"'^. V.
-t^V,
'â– '*^-
W"
r(
ii
' i
•'.
â– 1
M
• ' 1
i I
!!^
! i m
iFf
1
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
f ,,,,,,,,_ KVo 1- r^;*^ii:\ !•<•., REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/)(f/(' F/'/ff/, LI^vQa^a^aA; 'X^
lir<2i'Sfri'r(] JS^o,
I *-» * 3^^
v^ Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH-=City and County of San Francisco
Certificate of Death
PLACE OF DEATH: — County ofO/O/^Aj O^VO^^vo^^aCity ofOcX/^-u OyV<Xvvc^r- c
on
N
(jTv
-^1
and U.V.rvNC
o. T 0 \ iL .^WtjLV St.; S Dist.; bet.
/ ir DEATH OCCURS AW*V FROM USUAL R E S I D E N C E G 1 V E FACTS CALLED FOR UNDER SPECIAL INFORMATION ' ' \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
-OLhJ
PERSONAL AND STATISTICAL PARTICULARS
LL
1' +
U III
a^
a^'
S
rli^
hJUL^
IQO ^
(V.-;ii)
' ' K 1 J
ial fit"
! • \
^ \
\ \M1 t»|"
1 \!!! J-.K
I ' ' \ , 1 .'
.1 ' • \
â– '.N N\MI-
^•:<)Tm;R
illRTHPI.Xi I
'"• MOTIII-R
'St-Ut- f>r i'.Minti \
MEDICAL CERTIFICATE OF DEATH
DA I 1. < M I'l; \\\\ r\
I II i'.K i:rA' C l-.RTl I'W 'I'liiit I ;itlciiiK-.i (U-tL-asctl from
lli.it^' I l;i->t <;iw ll '- ,ili\t<Ml LCv^Mli 'Xf) K)0 ' I
1 that tlL';i'li I H(-uri(.'il, <>n llu- il.iU- staU'il abovt-, at v
a 111
M. TIk- CAISI': (»I' DI'.A'rn wa^ as follows
hlRXTION )V(7;-.s- ^ Mo)tlhs'-l Pays Hour>;
c( >NTK [ r.r 'I'oi^
/^yVAJl
DTK AT ION i )V(//.s
SIGI
^vV\X^ ',^-^ i()f,
" f.
rx.i.ircso bos cH
Hav^
k\.C\^
Tliuirs
M.D.
â– ^1
Special information on'y ''''â– Hospitals, Institutions, Transients,
or Rrrrnf Residrnts, and person*; d\in!j away from home.
)
•■Hi: AH()\i.'. <.i- \ 111, •,.»• K s, )\ \i. !■\K iirt !. XK-' \ K J ! I" K ' 1-: T" ' I'lir;
'•'"'■"■'!N i^^•« 'W i.i: III. 1-: AM) r.i;i,n',i-
Former or
L'siial Rcsidenre
Whrn was disease conlrarled,
If not at plate of deatfi ?
How lonq at
Plare of Deatfi ?
Oavs
l'I,ACl-: 111 !'.r KI \I, < "<: KllMii'v'M. I DATKo! IlrKiAi. .a KI;M(»\AI,
(A.i.
N'
. ».— Hvcry i.cn oV uifoiMn. tn.n «h.u.I.. b. ..rcn.Ily suppli..!. Adf. sV>uhl ho stnte.l KXACTLY PHYSICIANS nhoulcl
Htnu- CAIJSI: OF DKATH !n pl;.i„ terms, thnt it m:.y he properly cluKsified. The Special Information for p-r-
Kons dyinft awny from home shoulil he Ji"ven in every instance.
1 ''
' ' I
'-)
•i 1!
.1
J li *
i'
I •• A I
I .
K b C 0 K U S
TITLE
RECORD
SAN FRANCISCO
COUNTY
S AN FRANCISCO
CALIFORNIA
DEATH CERTIFICATES
I CROP I LMED
FOR
THE GEN EA LOG I CAL
SOC I E TY
OF SALT LAKE
C I TY
UTAH
CALIFORNIA
DATE
APRIL
1975
PH OTOGR AP HER
MAX J OHN SON
CAMERA â– N02683
k ED
VOLUME 1019 — 1325
904
ROLL
t
•
L 0 C A I, I T Y OF
RECORD S
TITLE
OF
R t CC • '_
SAN FRANCISCO
COUNTY
S AN FRANCISCO
CALIFORNIA
DEATH
CERTIFICATES
I CROF I LMED
FOR
THE GENEALOGICAL
SALT LAKE
C A L I FORN I A
DATE
APRIL
SOC I E TV
CITY
UTAH
1975
PHOTOGRAPHER
MAX J OHN SON
CAMERA â– NO 26831 RED
VOLUME 1019 — 1325
904
.if
ifl
if
Iti
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
H<i:ir
,1 of llcM'th- 1- No. i> ^•^•..«— ^v lU'vl' C
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
l)((fo Filed
\Xkkjo^kju^
"xx.
V)0\
Bcilisivred jYo.
12G2
io-cwi ILv^ Deputy Health Oflncer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( Xl. S. Stan^arc> )
. PLACE OF DEATH:
County ofC'/CU'^AJ 0 AXX/^^vCA,>CLCtCity of CjCLO\; O.V<X-vve^.^e.o
.; S Dist.; bet. 0 J^aJCutyv and U VftA^X'
/ IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' ' \
i, IF DEATH OCCURRED IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
\
FULL NAME
si:\
i> \ ri- oi I'.iK 111
PERSONAL AND STATISTICAL PARTICULARS
\XX'
VA^
ix
\.'
MMiiih'
AC. K
o<. O ) I at » O
10
(I»;ivt
M.mth'
r\%\
5
( '/t;il )
/'.;
sixr,!,).;, M \KK ii:i>
\\ n)<>\\i:i) nK i)iv<)K(i';n
iWiit) in '.iii'ijil (livi;.'niiti')ii)
Sl;iti or C'jiinti V
\ WW ( )l
1 \ I 11 l-.K
lUK'nnM, \<-K
OI- i'.\Tm-:K
(Statf or t."'iuiil ! V
M.\ii)i;\ NAMr:
ni' MoTMI'.K
HIR'niI'I,At"l-:
<>!■• MnTlM'lK
LL/vwcxxL<r\j N-<^ v^<x)
KXJuy^u<Aj<kX)
MEDICAL CERTIFICATE OF DEATH
DA'n-: ni- i)i:\TM r\
(Montli) (T (Day) (Year)
I ni;i<i:r.V CI;R'1*II'V, TImI I attcndiMl deceased from
tliMt I last saw li'i-^^v alive (Ml LC\.^Q XG Ti>o '\
ami tliaf dealli (iceurred, «>ii the date stated ahove, al v
\J M. The CAISP: Ol- i)i;.\ril wa^^ as follows:
DIR.X rioN
CONTRIIU'l
)'rors J. Mo'illn \ /hiys Hoiii
M,t)ii/is
1)1 RAT ION 3L )'riirs
(Signed) ^JvOl/cxxaj h /\olaa.>m(^^
/hry<
ic)o"i (.Address) b0 5
I lour a
M.D.
^1
SPECIAL INFORIVIATION ""'v for Hos|>itdls, Institutions, Frdnsifnts,
or Rfirnt Residents, dnd persons dyintj .may from liome.
"' >1 TAllON P [ i/\ (1
);,n,//,.
/i.n
rii 1" \!'.o\ 1*. s r \iiii i'i<Ks. »N \i. r \K 111"! I. \Ks AK }■, ri< ri'; ii > tin-;
IU:ST<)1' .MS K.\o\\ l.i:i).-,); AM) Itl.l.Il.I-
1 1 11 !' !• nriiit
\f)\AA ^ ^-^^ ^
-^'^
\,M..ss Toi UJjLAMiXj^ Ol:
Former or
L'siial Residence
Wlien was disease confrarted,
If not at pla(e of deatlt?
HoH lonq at
PJare ol Death ?
.. Days
n.Aci-: ol- liiixiM, OK ki:mo\\i.
LaJLcx/yv^xkLoj v-/cJu
TQO'l
I '
KAI'Koi HriuM, or Ki:Mo\Ar,
LIa^'CL. ll
IN. Ii. r.vcpy item ni 'iriformution Nhr>iil«l b- csiruiully supplied. MIV. s'lould he stjiteil I.XACTLY. PHYSICIANS Mhould
Htiitc CAUSn OV Dr.ATH ill plnin terms, thiit it may be properly cluHtiiritfd. The "HpeciHl InliormHtion" for pwr-
Rons dyinil iiwoy from home nhould he iiiven in every instnnce.
I
t 'i
^â– 1
I'
n
I' *
•
i
»' ,11
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
,,,,.,,,,,,,-, I, ,',h !• Nn \s^^:*y'i:-nScV(
Da/r Fih-'l, LLaxx^^ Q.1 l')0\
Begistcred J\''o.
1 2G3
Q\Jr^^^^KJs
Deputy Health Officer
DEPARTMENT ()F PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of Bcatb
( 11. S. Stan^arC> )
J? (?!} -\ ^
PLACE OF DEATH: — County ofU/Ct^ro 0.\XX^\C>UIC^ City of 0<>^^^ ^ AxX/>a^Ca.^C<j
P^
CHlir^/^txXA ^
St.;
Dist.; bet.
and
/ ir DCATH OCCURS aUaY FROM USUAL R E S I D E N C E G I V f FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
V IF OEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
xm^vu db
/CUYl
o'>\'
\\.^
-h
i» A ri: « II i!iK III
\<'. }•:
M..iith'
t
)•-,,â–
'S
'I):iv)
\r.,,,ih.
(Vt-ar)
l\i
>iNt,i,i-:, MAi<kii:i).
UIDOWKI) OK l)!\(>Krj: I)
• Wiiti in '«<)ri;(l 'If-it'iKitiMii )
r.Ik IHl'LATH
(Stall or Countrv
X.'
VAMlv OI"
jathi;k
1UR riii'i.Aci-:
OI- I Allll'R
iSt.ili ..! I'duntrv
M\II)I-:\ NAMI".
'>l MOI'Ul'.k
!;ik riU'i.A*)'.
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATH /O
(MoiitlO/f (Day) (Vt-ar)
I Ili:Ui;i'.V C"I;RTI1'V, That I attended <lcrcascMl from
to r-— -TC)0
1 90
that 1 last saw h ~ ahve on
•T90
aii<l that death oceurred, on the (hite stated al)Ove, at
M. The CAISI-: ()!• I)i:AriI w.is as follows
Dr RAT ION )'iu}rs Mouths /hjvs Uonys
CONTkllU'TORV
• K ( r 1' \ TioN
A' ijf'if III Siiii /'i ,!ih ! .-.I ' 1 , ,â– . â– .lA-',7//>- ( /></r
)'i(irs ^^ .1/'>f///is Days I/ours
NED) Ur\>cr^vii^^O.'€).lXV"ljl^
-0
DIRATION
(SIG
A.ldrr^s) L^\.CrvaA^ VAi
"wdL M.D.
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from fiome.
Former or
Isual Residence
L. [ , flow lonq at
OClVwJw^ V.<XU piare of Deatli?
iin-; Miov}.-. STA ri-i) i-kk-on \i, i-xururi.Aks aki-; trii-: t« » riii-:
IIKST oi- MV KNOWIJ.IX. !•; AND IWIJi;!-'
niif'>;inrmt
f \<1.1
S^x- x^ iiv at
Wfien was disease contracted,
If not at place of deatfi ?
3
<3?
Days
I.ACl", 01 lUklAI, OK Ki:Mit\AI,
I)A'li;<if Hi 1M\I. 01 ri-;mo\ai.
TQO'l
N 1 1 1: K T A K 1-. k \] l\ 0 XXcULtv^ \ K VSj AX/XAtu \ 0 U.t'^V
N. B. Hvery item of iiiformntion shoiiltl be cnrcfully siipplieil. A(]fi sJioulil be stntecl F.XACTLY. PHYSICIANS Hhotild
Htote CAUSE OF DEATH in pinin terms, that it msiy be properly cloHsiltied. The "Special Inforinution" for p«r-
snns dyin^ away from home should be given in every instance.
: â– it
i;
t •
I
i<I
M
I'
w
n .
i
:..[
i if
M
ii
WRITE PLAINLY WITH UNFADING INK
HJ*'*'*^
}!m:ii(1 mF I!r:iMh -I" N'o. l^ ^-V'^-^-^ l\ScV Co
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I)ff/(' Fi/cd ,
cMr'^^LA^
v^AaaXY^aaXT Os?>
lf)0\
Begisfcrcd J\^o,
Deputy hiealth Officer
DEPARTMENT OT PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( "U. S. StanC>ar^ )
PLACE OF DEATH: — County ofO/Oy^^^ OX/<Xy>^.xuAc.<City ofOo./^A^ J ^cx/-yxx!.\^.ci.o
i ]Ve.VAjtu ^ Woo^yxLv^, ub C^i^vtoa: St.; Dist.; bet. — — and
A / IF DEATH OCCURS, AWAY r R O M lu S U A L R E S I D E N C E G I VC FACTS CALLED FOR UNDER •'SPECIAL INFORMATION'
(IF DEATH
IF DEAT
H 0CCU|»RED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER.
)
FULL NAME
/OaXIvtO. > \ <J^'
u
!) \ I I- <>i I'.iK rii
M. l''.
PERSONAL AND STATISTICAL PARTICULARS
M.inllil
^\ , q
ilhiv)
yf.nil/is
rVVX
'^
(Vfar)
/Ki\.
â– ^iNi .i.i:, M\kKii-:i).
\\ii)( »\vi-;i) OK i)ivnR(.i:i)
'W'litriii social il(si<.riiatioti)
(Statr or t'oimtiy^
NAM!'! HI-
1- AIM i:k
r.lKriIl'I,A>K
n\' I AIHKK
' "-^t.it f ' r (."ciuiit 1 \
MA[I)I:n NAM)".
Ol" MOTHKK
<>!• MolllKR
(Siatf or Couutrv
A
MEDICAL CERTIFICATE OF DEATH
DAri-: Ol- i)i:atii
Xi
iDav)
vAa^^
(Yi-ar)
(Month) A
1 IN'iklU'.V CI'RTII'V, That I attendcMl dccvascd from
IXcvQ 'X'h I90M to LLla^ 3.1o
up H
that I last saw h .<• >>> aHvc on V^Aa-a^' 'X^ up H
and that death occurred, on thf date stated above, at -^ ^5^
^v. :\I. The CAISI- Ul- DI'A'III was as follows:
DIRA'IION )'ci7rs
C ONTkll'.rTORV
Months
Pax
I lout s
\j<kAj:xj
Cr>A^xrv<x,-. ^
9
l\i'>iilfd in Siiti /'i iiiii isi'n 3> I ^ ' ''
;)r RATION o(^''"A (^ -'
SIGNED) J . VJV. ()\j
LV^^V-Q^'l T (p\ ( A d . 1 ress )
/hiv
Hours
M.D.
obcs^^^xlj
Special Information only forHttpitdls, institutions, Transients,
or Recent Residents, dnd persons dying .mviy from home.
former or ^ ^^
Usiidl Residence <^o I
\1/<CA,XX'
VA./CL
How lonq at
Place of Oeatfi ?
Davs
'1 .1A.^////.V P, /'.'!
'nil'. MKtvi-: si'\ii- 1> I'l: K-;<)\ \i, r\R iirn.AKs a hi-; •I'Kri". n • 'nii-:
r.i-.sr Ol- Mv KNuw i.i:n( ,1-: and i{!:i,ii;i"
Infoiiiiant
I-jL^ ^ J Xccto
f\(l<l
ress
^V.
t..\
^-^L-Wt
When was disease contracted,
If not at place of death ?
i;i,ACK Ol' luRiAi. OK ri;mm\\i.
DA'll'.o! I'.i KiAi. or K1:M0\-AI,
IQO^I
; NDKRTAKKK yO-t^VU^ \. O <xJ!Xcv^V\J?A; *^<)
''Adrln-ss
ao ' 5 JU>
N. B. F.very Item of information should be cnrefiilly supplied. AtlB should be stnted liXACTLY. PHYSICIANS should
state CAUSE OF DEATH in pljiin terms, that it my be properly classified. The "Spccinl Informntion" for per-
sons dyin[^ away from home should be (^iven in every instance.
■A i'«y
w
w
« I
\<
"^^
fT"^
;*•
1;'
HH
â– *
" i 1
,#:,
WRITE PLAINLY WITH UNFADING INK
HmiikI of nc.'ilth )â– V'
liljw^*»%.
liX: 1' C<,
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
B('(^ii<terc(l J\'*o.
iJ2G5
lUilr /-Vyrv/, LUv^ vv^t X% l'^0'\
Xfrvv^ Ix/v^u. Depu- , •t?' Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificatc of IDcatb
( U. S. StnnC>ar^ )
PLACE OF DEATH: — County of CJcu^aj 0.\.CU>x<^L.^c<iCity of CJ/CXo^ 0 .^<X/vve,^.4.c^
/^^
'^VXCM
OA^ v<St.4xX Dist.; bet.
and
/ IF DEATH OCCURsAaWAY FR<X USUAL R E S I D E N C E G ! V E FACTS CALLED FOR UNDER "SPECIAL I N FO R M ATI O N 'â– \
V, IF DEATH OCCuUlRED IN JjHOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
\XXXycL
;V
PERSONAL AND STATISTICAL PARTICULARS
'i:\
OAX
COI/)R
,\jJ<X
t
i»\ii': tfi iMKiii
A I ,!•:
MEDICAL CERTIFICATE OF DEATH
DATE C)l'- i)i;ath
pIv; I go H
(Day) (Year)
I Moiitli
•Davl
( Vrai )
?)^
) ,â–
.!/-â– ;////> 1 \ P'lv.
uii)i i\\j-:d Ok ni\'(>Kvi:i)
Wiitcin ^'K-ial di vi}.'niUii m)
iuKTniM,\oi<:
' Statf or t."(iuiitrv'
!â– ATH J-:K
niKTtn'i.Ar}-:
Ol" lATHHK
' â– 't.iti (ii Co\u)trv
ol moi"iii;k
Kikiin'i.ArK
oi- MoTm':R
fSt;iti' nv ('i)untry)
A'y\j
o^>ucL
/OAaaK^ciX
'0
(Month) /'
I 1II':R!';BV CI^R'rri'N, Tlmt I attc-n.K'il (U-ivased Inmi
-to —
up
that I last saw h alive- on
â– l()0
I()0
and that (Uath occnrrtMl, on the dato statrd ahovt-, at
— M. 'Jdic CAl-Slv Ol' 1)1 -A Til was as follows:
^1^
DIRATION
C ON T R I lU'Tl ) R V i.'PvLl: ifVO^>V 1^ cl.cL'^.:\
Mo)iths
V
/)a\
< KATl'ATION 0. '^ /)
h'fsiile'ii ill San /^i am i.-''i> ol U )V(M â– >
}/.>i>f/i< - />.
THi: AHo\ i<: sr \i"i:n im-'kso\ m, i'ari'hti.aks ah i; tkik to rui-:
r.HST ()!•• MV KNO\\"!,l.I)(.K AND ni-.Ull". F
(I
(Address I ^ ^ ^ "1 Xa\} O't
nr RATI ON )'rars
( SIGNED ) L(r\CA^n
'^ ^
H
Mo tit lis
\
Pavs
^\ i(,o^ (A.ldrrss) WuHAjA^
Hours
M.D.
Special Information only for Hospitals, institutions, Iransicnts,
or Recent Residents, and persons dyini) away from fiome.
Former or ^.^ . (W \ ^ How lonq at
s 0 VI rWroo^ya ^ piare of Deatfj ?
Usual Residence '
Wlien was disease contracted.
If not at place of deatli ?
Days
ri.ACl-: Ol' jnKlAI. «>R R!;Mo\AI. I DAlIi^.l i'.iKiAi. <.i U1.M(»\ \I,
I LAa.VC\ 1^ TQOH
(Address " H^- 5 I T)^W vW-V
ri, AC J'. < II' y,\ K i.\i. « Mx. I'
INDl'.K TAKMK
IN. B. F.very Item of information should be cnrefully supplied. AGC should be stated F.X4CTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, thnt it m»> be properly classified. The "Special Information" for per-
sons dyin^ oway from home should be feiven in every instance.
I ! '
i'
*â– .
!'
i'
*t
r«
WRITE PLAINLY WITH UNFADING INK— -THIS IS A PERMANENT RECORD
I!. .-,!
,1 ,,f II. .iltli !•■Vo. l^;
â– *'^'owr'^' ]'.^V C
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
i'
II
' ,(
Bc^Lstered J\^o.
\2m
rrtf-^ •
Ihilr Fih'il, CLwcv^^^il X\ V'tO^K
{ \^ -
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of ©eatb
( 11. S. ♦5tan^nr^ )
PLACE OF DEATH: — County of U/OL/^rv 0 ^^CX^ruCUIi/^oCity of CJ/CXA\; 0 ^^/(Wt'CA.c^c <j
O^^^MUaa Llv-t St.; ^\ Dist.;bet. U/oJk nnd
/ ir DTATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER -'SPECIAL INFORMATION â– ^
V, !F DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
No. \\
FULL NAME
Ow>-v
PERSONAL AND STATISTICAL PARTICULARS
OTN a ' rnl,(iK
>i;\
i»,\ri". oi- liikrii
(K<r^r
NT.iiUhl
I):iv)
rVxl
\ ' . 1 â– ;
15
)■<■-■» ^
^
M.niih-
M
'•>■. Ill
/',/.
>^i\«",i.i-:. M\Kkii:i»
wiiM i\\i:i) (»K iii\'t iKri;i)
Wiiltin social (lcsi;.'nalic)n)
lUKTUri, At'H
i 'stai,- or <"Mniiti \-^
iMxriii'i, \ri.:
OI" lArm.K
(SlatL- or I'otiiitrv
M mim:\ n amp:
<'!• MoTlll-.K
HIKriil'I.Ari-:
<>i- Mn'rin:R
I stall- or Country')
ovTri- xrioN
ty\A) cLc-v^ui 0 ^j^'O^aoJUr^
a^Tv'
\AxtL
VX'W
>s v
MEDICAL CERTIFICATE OF DEATH
DATK (>!• ni'.A 111
at
(I):iv)
(Yffir)
fMoiitli)
I lli;Kl';r.\' CI-RTII-V, Tlmt I attciKlcd .Icci-asLMl from
CL^ 'W 190 H t,, 0^ 'Xb i<,oH
tliat r last saw h -V^.^ alive- on U-^-va Xb 190 'I
"(f
tliat iliatli occurred, on the date stated above, at 0 • 0 O
M. The CAISh: ()!• Dl-ATII was as follows:
DC RATION
)'(•(/ r.s"
Mou/hs A /^ars Hours
DURATION Years
(SIG
.\CU>V>Cll
Kr^iilrd ni Sii>f I'l atii : •■i'(i I >A ) rii i
1/..///A.V
n,i\
THi-: Mu»vK sr \'n:n i'kksonai, rAkriiM i,aks aki' rkri': ro 1 iii".
iU':sT m- Mv KN<)\vi.i;i)('.K AM) in:i<n:i-
(I
nfoMnnnt fcx/Wh^ dUv' VA VJ JkjJLa.^^ MfX/oU
)JUWJ\AJi
( \.l(h.'^s
1 1 U /cx/>v \j\jL<lo LL
VhJl
Mouths fhiys
NED) v\ - \jxAj^.j<J-<xXXy0^6u>J\.>
Hours
M.D.
LAaa.<:\,?k'1 i()oH
(
Special Information "hIv for Hospitdis, institutions, rransients,
or Recent Resident?, and persons dvinij <m.iy from home.
Former or
Isudl Residence
When was disease contracted,
If not at place of death ?
How lonq at
Place of Death ?
Days
J'l.AD'; ol- IM'klAI, ok kl'.Mo\AI<
DA'ri; o! 11- !-• I \i. oi ki-;M( )\ai.
VI I, '
1
Ni>i:kTAKKkM U J CuL(U/Yv NK^vij^JUXAli^^ J\X^\
!on Hh.u.1.1 he caro^'i.!l> suppH.d. ACfi s'louhl be stnte.l EXACTLY. PHYSICIANS should
H in i.hilfi terms, thnt it miiy he properly clnssiried. The "Special InVorm.ition" Vor p«r-
IN. B. Kvery itein oV inforiiiiit
stnte CAUSF: OP DEA T
sons dyin^ nway from home should he fiiven in every instniice.
Ill
11
• 1
\ 4
I â–
p
r I
I
i.i
It
Hi
I'*
• ?
; >
f:i
fe
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
i(! ..f n.-:i!!!i- I" V<i. !< "^""li^j/""' Hi'viPc"
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
1
O^^'V-^'3
ai
7,9/9 H
Bvi^isid'cd J\^o.
126?
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco
Certificate of IDeath
( U. S. StanDnrC^ i
jj am ^ ^
: — County ofO/CUYV J A.<XA^C\AC'.City ofUo^/>'\j J /\^€LAA^Cc4 C <
PLACE OF DEATH
No. 1\1
VWk-N;
St.;
^
Dist.; bet. lU O.
and (]v)-<XA.QA\t
(ir DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V ET FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
>i:\
i» A I'l-: I )i r.iR 111
PERSONAL AND STATISTICAL PARTICULARS
I COI.oR
Wy^
OL\i
Wvj
C^-
'XCOX:
; \'A t T I'
lilt h
(I):tvt
.\<.I-,
X\
) I ll I
.!/./;////<
h
/>,n.
MEDICAL CERTIFICATE OF DEATH
^!\< i.i" M \ki< ii:i).
W MX tWI- I) i\H I)l\"(>Ktl':i>
Wiiti in <oci;i; (1< sif.Miation)
lUK riiiM.AvM-;
(StntL- or I'omili \^
»•■\riii:i<
liiR rni'i,A(.K
St;itc or Coiiiitrv'i
M \II)}-:n n \mi-
<>i M()Tiii;k
i'.IRl-UIM.Ail-;
<>i" Morin-.K
(Stiitf or Count rv I
^
CUi
<x>'v./cL
I)ATI<; ol' ni-ATH /O
(Montli) jC (Day) (Year)
I Ill'kl'lJV Ci':RT!I-\'. That I attrii.U-.I .Icvcast-d frntn
vAx^x3i X'l ]()0^ to VWw^ 'X% up H
til at I last saw h -^ >>v ali\c- on \A^^-v^ '^X.h up ^[
aiij that death ocrurre<l, <iii tlu- <lat«.- statcfl ahovr, at I 0 . Ho
■0 M. Thr CAISI': ()!• Dl-ATIl \va^ as follows:
DrkATfON }\urs Mouths % /hiys IIoux
CONTRIIUTORV
1)1 RAT ION
f SIGI
M out In
NED)Ll). 0. O.^AXcLlvCrWv
/\}Vs
â– TVCLAAj
l\fsidrd III Siiit /'/(;;/( /v<> JL' 1 )',-,! i^ [ .y/->ii//l- i)
ATI'ATloN (TTJ
0 A>uK-/VVA, "■«
\j
//ours
M.D.
fN. > I<)0 \ (
\.Mri-SN) i^S'^T* lb>Uv) Ot'
Special Information "niy tor iiospitdis, insniutions, ir,insienfs.
or Re(ent Residents, and peisons dyini) .m.iy Iron home.
/>,!
I'll I' \H()VI' ST \!-i; I) !'K K'^DX \I, r \K I I.I I. \k^ \KI. rkii
iu-;sT oi' Mv KN()\\"i,i; ix; i: and ni.i.ii;!"
: Ti • Ml 1-:
' Iiifo:in;tiit
former or
L'sudI Residence
When was disease rontrarfed,
If not al place of death ?
How lonq af
Place of Death ?
Days
I'I<.VL"I-- '•'• lilklAl, Ok kI-:M<»\AI.
\i.\'l'2:. of UruiAJ. or ki:M<(\AI,
I
\(1<lri'.is
N I ) 1 ; k T \ K 1-; k VXXAJUaT ^^ W\^^X>Aa^'(Jv\j
N. B. l-,very item o»' informtition fthould he cfirofiilly siip|)lie<l. Adfi should be stilted fiXACTLY. PHYSICIANS Khotild
state GAlJSr OF DLATH in pinin ternis. that it m:iy be properly classiried. The "Specin! Inlrormiition" Jor p«r-
son« djinft oway from home should be iS^iven in every instnnce.
f
i . J •■; .
lit
I •! .
P^
17
i
â– t
1
i i
pf
>
1
i 1
'lift
nun r
i
(<
(I li
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
i;,.:inl ..f Hr:i!tli -I" Nn
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dff/r Filed ,
X\
U)()'\
Begisfci'cd J^^'o,
1268
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( "a. 5. Stanc>arc> )
PLACE OF DEATH: — County ofUOAv OAXX/^vCv^xU) City of OxX/>x> OAXVrX'^co cc
a
AJro
•tti-
No. l^C)1 VJ rL^'>A.^x.CX' St.; H Dist.;bet. T ^LA\) and o /^vxj
(IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" N
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
si;\
PERSONAL AND STATISTICAL PARTICULAR
I COI.ok
^^UoJU
'XA.
ti
1> Nil". <)!' K I Kill
\(.i-;
\til.iitht
X
%2,
fl):iv^
!/.'»'///â–
(■/(•:irt
MEDICAL CERTIFICATE OF DEATH
DATl'; Ol- DlvATJI
LLl^
n
(Day) (Year)
^I\«.l,»:. MAKKIi; I).
U IlM»\\i.-,i) OK I)!\'oKri-:i)
Wiittiii >.(n-iril il»-^i-.'ii:il !■in )
lilKI'Ul'I.Ari-;
'State or (.'oiinti \i
NAM)'; ol
i-.\Tni;k
HIKIIlPI.Ai}-:
Of- I'ATIII'K
'SiaU' or r<nnitr\
MAII)1:n NAMi:
Ol- MiiTIIKK
inurni'LAri'.
<'!â– MOTIIHR
'Stiitc or Oounlrv)
(Month) A
I 1[I-:RI:1'.V CI;RTI1-V, riiat I .itUii-K-.l (lovasfd from
LLc^wOl %1, 190 H t() CUa/Ol. M iiK^H
•%
tliat I last s;iw ll ^>^^ alive on \-A.-\.ax:\^ '>hI> 190'i
and tliat death occurred, on the date stated above, at v>
VV. M The CAISI-:
Ol' l)i:.\TII was as follows:
DIRATION
) 'rars
.1/0/////S -i Days Ilom.
.'^JL^i,
â– S ^- .^n^Ht/lS
DIRATION )',iii
,NED) U). U- . Xuit
/h7\
'S
( SIGI
CjL
«)t.i:ri'ATi().\
Rryiiird III Sat! /'i ii ni !>i',) )V(f;> ^^^ Miiulli^ (Q
Hours
M.D.
W TooH (Addtvss) '^'ii '(fb^c<Mx.vfC ot
Special Information "nl> for llospitdls, Inslilutions, Transients,
or Recent Residents, and persons d>inij dHHV from home.
Former or
Usual Residence
Wfien was disease contracted,
If not at place of deatli?
HoH long at
Place of Death ?
Days
'rm-: xnoxi-: sca ri'n im-ksi )\ \i, !â– \k ricfi. \ks ak i; {â– Rn-: lo riii'.
ni:ST (H- MY KNoUI.l.Ix.l-; AND luaji:!"
nnf..;ni:,nt
Yc4v>v \LcL'v\^lj!)-duL
^\.Mi,-. Ipon. M Jtv^w-^v^o. ^H
iy,\ei;ni liiRiAi. or ri-.moxai,
iNH)-; Ki
rj, \i )-, • >i m K i.\ I, < »K K I-, :>
DATI'.o; \\y\i\\\. or RilMtiVAi,
^-^U^Cl 'iO T90S
(Ad.li.-.
II 'i^ Qi^'V^.^i.^v^x. ot
iN. H. Kvery item of information shouUI I)l- oircfiill.v siippliiMl. \(\V. slioiild be Htnted F.X4CTLY. PHYSICIANS Rhotild
state CAUSE OF-' DEATH in pliiin tf rms, thnt it mjiy he properly classified. The "Speciiil Information" for par-
sons dyin^ awny from home should he ftiven in every instance.
\
'It: IP.^
S4
n -' \ ^
hi'
I ^•''
i i
B:
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
i;,,,i.l ..f Il.iilth »•■No : - -^'f^^^^i:. ]Mk V C
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
ill
ii:;
D/f/c Fi /(>(/, LL^v/O/CA^ 3.S
100 "i
Jiro^i.sfr/'cd A^o.
1269
cU^...,^ "Ix^vM. Deputy HccJthOflfloer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beath
( U. 5. Stan?arc» )
^
'(5Tl
<^
PLACE OF DEATH: — County of -' Oy^ru 0 -^'a/>vOL-5.co City oi^Ou^^ J A.<X/>Ayt^v^c<5
Na cl3.3>'(
•< ^ll
m
OUCLt .
(IF DtATH OCCURS AWAY FROM USUAL
IF DEATH OCCURRED IN A HOSPITAL
St.; I Dist.;bet. 0)LXX^TVCa^^U) and ^Vt^'t>VL«^l )
RESIDENCE GIVE fac
OR INSTITUTION GIVE I
«
TS CALLED FOR UNDER "SPECIAL INFORMATION • "\
TS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
r
Ou
Q.>
PERSONAL AND STATISTICAL PARTICULARS
I' \ I'l: I "I- iiikTii
XjaxjJ
â– 'y\\j^.y Kj
\>.K
%1
(Dav)
/I 6
MEDICAL CERTIFICATE OF DEATH
DA ri". Ol" DllATH
1%
(Mnllth)
I(c
) ,. -;
1
.1A>;/.'//>
/'(/)A
^iv. i,i:. M\uKii;i),
\\"llM)\VI-:i) OK DIVOKCi:!)
liiRTnri, \0K
' Slatr or (/oimtrv^
XAMl' Ol
I- ATI 1 1 :k
i;
I Dav)
(Year)
lllvRI'HV Cl-;kTII-V, Tliiil I :it(c-ii.lc(l (IccoascMl from
^OQ ll 190 H to U.vv<X. '^"^ KpH
that I last saw h .*-'u alive on L^v<v 'X% jcp 'i
and that (k'ath (irciirrcd. on the date stated ahove, at 3v
AJ M. The CAISI-: ()!• DI-ATll was as follows:
O-uto-Ol^
HIKTm'I.ACK
<>l' I-AT!IKR
' State .)]• Couiitrv
MAIDl-;\ NAM)-
<>J" MOTIIl.k
inkTiiiM.Aci-;
<»l- MoTHKK
(State or I'oiiiiti v'>
<>' 1 Tl'A riox
/\'f .'iffif i II Sail I'l ii â–
^^ ^ \.tci'<xo^tr^
DIRATION )'rars MoulliR 3 pava \X //<>tns
CONTRIIU'TORV 0 -CjAvn<<^vcC J^vsi^v
nr RATION }'rars Mi^ulhs ^^ /),/is- 1 lloun^
NED) 1). V^.^i).
(Signed) cU. Vd. ^^'»<xcA^aoXA.vi\u
M.D.
eJi
ufii
SPECIAL Information <'"'!• f"f Hos|»ildls, Insfilufions, rrdnslcnls,
or Recent Residenis, dnd persons dyin;j <iw,i:. Iro.ii home.
*- M.nlll,^
n,i\
\'\\V. \\\n\'V. S'l" \ l"l"D I'KRSONAI, I'AKI'lif I. \Ks AK I-, TK II': To TM l-
iu;sr Ol' .MN' kn'owm: D<". K AND^in:i,ii:i'
'infci'iuatU
X'l'ln^^s
wx\
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How lonq at
Place ol Death ?
Days
DA I1-: o! lit KiAi. or K1;Mo\-A1,
L\.>-vx:l "^l 190M
i'l.ACi: Ol" MIKIAI, OK KI:MoVAI,
t • X D 1 • K T A K I- K U oAjU^T^XjL \J j\ O^^^ A./WO ^^^ K^ii
N. B.
iJiMLik
-r.very item ni informiition should be cnrot'ully s ipplied. AdB should be Htiiteti r.XACTLY. PHYSICIANS nhould
state CALISn OF DEATH in pljiin terms, thjit it mjiy l>e properly classified. The "Special Infopmation" for pur-
sons dyinji awny from home should be (Jiven in every instance.
I '•}^l
<
:|..
I."
i
; ii
oi
Ml
iJu.^.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERIVIANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
l>,.:,i(l of n. ;iMh »■• No. - - t>-*"^ar;._^-~i. I!.'^ )' C*
Dff
/r rifrd, \X
wo'i
Be^istcred J\''o.
1270
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeath
( 11. S. StanCarD )
PLACE OF DEATH: — County ofOct"r\j J /VO/VuCXsU:^ City of Q CUYV 0 ^UX/TVC^^A^C c
No. 1151 J CrUL<rY>v St.; H Dist.;bet. T Ajk) and %J
(IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL I N FO R M ATI O N '• N
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME ^i) <xaJUulaX JyTUrrruXA \jOJ
PERSONAL AND STATISTICAL PARTICULARS
SKX
I' \ii' < )i );iKi!i
x<.i%
Coi.tik
IdJLu
MEDICAL CERTIFICATE OF DEATH
(k
Motit
n
)'i\t I
l
M..),lli^
•k\
l\i
\VII)( iWK.I) «>K I)!\<)RrKI)
'Wiit<'iii s.»ri:il (l«-<iiMiali<)ii)
lUKllll'I.Ari.*.
'stale DT Couiiti\)
LAaa^<
11
'Davl
(Year)
(Month) Y
1 1I1':KI{1'.V Ci;RTn-\', TIimI I aUciKkMl dcHvasca from
UU-A^ XI UjoH to LLuw^ al U)o\
lliat I last saw li i-"^•^ alive on vAaa,Q "^
atijl that (kalli luHnirrcd, on the date stateil above, at O
T90 M
M..Tlie CArSl{ Ol" DI'.Aril was as follows:
a
\A>ti-: Ol-
I'A'iM i:u
Hik iiii'i.ArH
ni- ixrui'ik
'Stall 111 C'tuiitiA"
MAII)1:n XAMl-
Ol' Morm-k
I'.ik riii'i. All-;
<•!■^!^>'|•||l■;k
'Slal.' Ill Coiinf ! v I
• " I r I' \ I'K (\
^
Oy>v J AXWV'^I^L^ C^
OJ^
^
'/<X/w» 0 AXX/> vc^^-vc^
m" RATION
) 't'ar\
Mouths ^ Days Hour
C()NTRIlU'r()R\' V.X'C^aAJI \j<xaXaaX^
lx^J>uv^^ VD,Ol>
J QSTl
I ) r R A 11 ( ) N
(SIGNED )
)'('itrs ^ M ("it lis
%
0 Cr ^-\^V\)
<vo
Piivs
\Xk^<\ 1^ic)0^ (Address) UIH. 0&VL<r>W O.i
I loios
M.D.
^
Special information "nly tor Hos(iildI>, Institutions, Trdnsienls,
or Rercnt Residents, and persons dylnfj .mny from home.
/\'f'^ idf'il in Sttii I'liiiui '
) -
v\ 1/ .;//-// vOv I
' ',
'II I'. \ii( )\i.: ^i" \'n: I) im'Ksi in w, v \k iut i, \ks ak 1: I'k vv. ro rii v.
iii'.sr Ol- >.Lv KNo\\i,i-i)(;i-. AM) r.i-;i,ii.i-
(h
Ill'.Sr 01- >.LV KNO\\i,l-I)(;i-. AM) III
'fonuant J ytx<rv>A.x>^ v^<xaA-xs-aX
0 crVA^rvA; Ot
i \.Mr<-KS
\\%x
Former or
Isudl Residence
When was disease fonfracfed,
If not at plare of death ?
How lonq at
Place of Death ?
Days
I'LACl'! OI-" IMklM, OK kl-Mo\AI,
V
(ibcrw La>6-M'
N I ) 1 ; k r A K 1-; k OvD . J . O-'U^
r\.i.
I) \ l"l. ..; li! luAi. or ki;M<»VAI,
LU/^ x^ 190H
N. K..
-\\\cry Ucm «.*' informnlion should b^- cnrclfiiliy suppMcil, AdK should be stilted I.X4GTLY. PHYSICIANS should
stntc CAUSf: OP DLATH in pinin terms, thnt it mjiy btr properly cinssilflcd. The "Speciol Infornuition" for per-
sons dyinft nwny from home should be ftiven in every instnnce.
I ill.
'Mk#
\l i
f:,;i
'ji
' f
ii
'I' i\
H' .1
.1
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
1!. ..•!
nl ..f ncjilth I" No. I- "^-^^^^"^ 15&1' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
as
I'JOH
Kc^iKlcrcd J\''o.
1271
Deputy Health OfTlcer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of IDeatb
PLACE OF DEATH: — County of
City of U /OL/^^^CXTL VA>X>>J
No.
St.;
Dist.; bet.
and
/' IF DEATH OCCURS AWAV FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS N A IVI E INSTEAD OF STREET /> N D NUMBER. /
FULL NAME
O/Ol^)
0.
^x<s\HX'y\j
s};\
i>.\ 11-: <>i' HiKTn
PERSONAL AND STATISTICAL PARTICULARS
K<.KA
i:
AC.K
D.iv
:/'»///!.-
MEDICAL CERTIFICATE OF DEATH
DAi'i': <ii i»i:\ I'll
a^
(I);iv)
IQO H
(Year)
0.1
/'.;
^IN»',1.I-:, MARKIi:!).
WinnWKI) OR DlVoki}-;!)
'Writt-in social iksi^'iiatioii)
lURTlU'LAiM"
(State or (.''niiiti \ ^
NAM1-: ()!•
I'ATlllCR
HiRrilPI.ACK
<M- lArmiR
'State or Conntrv'
1^ f^
MA11»1'.\ N
1 Jll'ik i:i'.\' Cl'R'i'I I'\', Tliat I attciKkil (U'ceased from
-^ — 190 \.o 190 "
lliat I last saw h alive on — — — — : — - — - 190 —
aii<i that (K'alli 1 )iH"itrr(."(l, on tlu' i.\.Ak: sl;ite(l alxn-c, at
Tv.M. TIk' CArSl<: Ol- DI-ATII was as foUnws :
~ M. Ill'
DC RAT ION Years
CONTRIIU'TORV
Mouths
Pa \s
Hours
IMRrniM,ACl>:
oi- MOTIIKR
(State or Cotmtrv)
r 1 1
OCCri'ATlON
Rfs'dfij in San I'lnii, :
rVTLAXX)
DT RATION
(SIGNED )
\A^v<
Yrars Mouths
1". r(,o'\ (..\.1.1rvs^)U^<X>.
Pa vs
Vi:-'trA^v^vMX'
Hours
M.D.
(EC
Special information "nly for Hospitdls, institutions, Transients,
or Recent Residents, and persons dviny dwa) fro^n home.
)V,M
M.'lltiK
IK:
Tin-: AH()\'K sr \ri:n pkksonai, i-AKin'ri.AKs akI'! rurK it) •imi-
I5K,ST OI" AK KNOW 1.1 ;i)C.F, A N I )Hi;i,l l! I-"
^InfoiiiKiiit
\.Miess V
Former or
Usual Residence
When was disease contracted,
If not at place ijf death?
How long at
Place of Death ?
. Days
rr.ACK OI" lUKIALtiR Ki;Mt)\A!,
CcU 0^
DATI-;
1
rXDHRTAKl-.K <3jLAjfc<Jkj ^ (/VX^^daA^A.
OoJlLvw^c Let
; Ri.M. 01 K i:M( »\- M,
^1 1 90 H
fAcl(lr(
N. B.— Hvery Iten. of Information should be cnrcfuMy suppr...ci. AGB should be stntcd F.X ACTLY. PHYSICIANS Hhould
state CAlISn or DEATH in plnin terms, that it mjiy be properly ciussified. The Special Intormiiti >n Vor p«r-
Rons dylnft away from home Hhoiild be Ji'ven in exery instance.
* â– ?
\
I til
|i^
' >'
w
1.
f
p
I'
w
hi
I
i
4
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
|'...:ir.l >â– ( 1I« ilili •â–
V,,, ;-, •?■--• -=.-.^: IKS:
1* (â– (!
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Regisfcred J\''o.
i^?2
ihUi' ri/cdXl^o^A^^^ XH /'"^^^^H
dUyvcvo Xitovu Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of ©catb
( H. 5. Stan^ar^ )
ro
PLACE OF DEATH: — County of NLf LCL^V-n. >x'
City of
cr\t*i H I l<xcLi\.a- La'
No.-
St.;
Dist.; bet*
-and
/ ir DtATH OCCURS *\A/*V FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION • \
l^ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME 0(Vfvlv^. OxcO ' '
U)l.t ~
PERSONAL AND STATISTICAL PARTICULARS
MX (^ 0.,...K
iiA ri-: <•!• r.iK in /P\
MEDICAL CERTIFICATE OF DEATH
DATK til- Di.Aiii ry
a'i
(Month) K
I ni;Ri:r.\' C'I:RTI1'N', That r attcii<UMl dcreascd from
(Day) (Year)
> ( ;tl i
bl
/),;v
'-INC. 1. 1". M.\kKii:n.
wiix i\\i:i) ( iR i>:\( iRri:i)
Wiili ill v,„i;il il. --i^'nat ion )
IMRTMfl.At^K
'~'t;it !â– I ir < "iiti nt t >'
\\
<xsjv>-^cL
iX"
NAMi; (»l'
FATin.K
iiiKTnri, ATK
<)!• I-Aim-.K
I Slat r or Count i\
M \I DI'.N NAM1-.
01- MoTin-.K
Hiurni'UAci-:
(State oi roniitr\^
lL>vk
1 90 ti)
111 at I last sMw li -■alive on —
190"
190"
and that diath occtirrcd, on the <hiti' stated ahovo, at
M. The CAlSIv Ol- hIiATII was as follows
DC RAT ION Yrais
CONTKir.rToRV
Moulin
na\!i
Hours
OOCII'AIMON
T
Mouths Pays
or RATION"^ Years
(Signed) J/lxxav
Hours
M.D.
ecTalTnfo
Special information onlv lor Hospitals, Inslifutions, Trdnsicnts,
or Rfffnt Residents, and persons dyiny dway from home.
\'f'itlrt! Ill Si;;.' /'iiUh: ('w O '^ )'..','
M.'iilh^
h.:\
Till': AHOVl-: STA'n.O I'KKsDNAI, I'AK 1 MTI, \Ks AKl IKD-; To III l-
1U:ST OI' MV KNo\V!,lI)(.H AND I5i: l.Ii: I'
(Info:niaiit Nil. \l<\. <^ JL/&JO^
Former or
Usual Residence
When was di<.easf (ontrarled,
If not af plac e of death ?
How lonq at
Plare of Death ?
Days
ri.ACK Ol- lURIAI, oK Kl.Mo\AI,
INDl'K TAKl'.R
(Ad
1
itA'L}'"! li! HiAi, or ri-;mo\-ai,
^^ I90H
N. B.
— P.very ite. of infor^BtJon .hou.d he cnre.'u.,. supplied. AGB shouU. «>« «*«^^;l^^->^.^i^^»'.^. .rrjul^' Vr'::!.-
«t«te CAUSE OP DEATH in plnm terms, thnt it mny be properly claHH.t.ed. The Specml Intormat.on for p,r-
«on« dyinft away from home should he Jiiven in every instance.
I
ii«.^
\f^
1 1,
11
;;â– <
!n
L_
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERIVIANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
)i,,;,i<i ..f II. iitii I- N" 1^ ■^^:."=^:'?'•• li^i'^
nnj'i
X6<A.A_xi Ai?/NM. De"-rtv MonftH r>pq-^«r
Be ^ isle red J\^(),
iS73
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificatc of Beatb
( tl. S. Stan^ar^ ) ^
PLACE OF DEATH: — County ofO/Ct-^Aj J^a >vcv^e{ City ofO<X/>^^ 0 ^vOci v C cA, c o
ivCLa..!
St.;
Dist.; bet.
and
/ IF DEATH OCCURS AVWAyIfROM USUAL R E S I D E N C E G I V E FACTS CALLFD FOR UNDER SPECIAL INFORMATION \
V IF OEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND N'JMBER. /
FULL NAME
)XcCt/VA.XLX
(X\-<^o\.(.
PERSONAL AND STATISTICAL PARTICULARS
i>i i'.iKrii
It
+
^-
,0 V-
]-'
,1 )
\«.I-
)',,M
S
M,,)illn
I'i
/',/,
SI\(,I.I-. M\RUIi:i»
u'lix »\\»-, I) ( »u i)i\ < >i/i i;n
Wliliin s.iri.il <lrvi'rii;it iiiil)
I'.Ik rillM, M'l".
St;M< .Jl I "•iiuill \'l
. \ \1 1 Oh
I \tiii:r
lukini'i, ATI-:
'>!■• i\rm;K
'State nr C'ntiiitrs
M\II»i;n- NAMl.
'>!• Moilli: K
iilU'IlM'l.ACJ-:
"I M<»riII'"K
-1 '1' ■•! (''(Ullt 1 \ '
OuVvwo
MEDICAL CERTIFICATE OF DEATH
1. A i").; * ii Di; \ III /O
\XXXXX. '^^ IQO^
'Mniith) K (Day) (Year)
I in';Ki;H\ ^ l, ••J'III'W That I atlmik'il dccrasod from
^jKaAaa '\ ii/j^ to LLla^ Xt» KjoH
tliat I last •^aw h '.'v; alive on 'sAa^VCv n\ k^o"-
and that (U-atli o(H-iirretl, on tlu- datt- stated above, at i
.; M. The- CArSI{ Ol" DI'.A'ldl was as follows:
0 jluWucaaJLc^.\.' LaJj-^ -tLXA^
4(S
Ow^i-X
DIR A'l'IO'N
CONTkllll'lORN'
> )V(/;.v
.\/nii//!S
fhns
/ fours
DIR \TI< »\
/hivs
' lit ri'A rioN
f/oius
(Signed) ^^ \X). ^aX^.-> '^ M.D.
â– 4-
I,,o'l rXddress) 3lH lo QaALe^^
Special information •»"'> '"^ Hi'spH'ils, InstHulions, frdnsu-nts,
or Kt'if-nt Rcsiijcnls, .init persons dyiii'j .iw.iy front homr.
I-
) - ,7/
1 1/,,,////. it/'
TIM' \!l<»\)-. ST \i"i: I) IMrKsOV \I, f \ K T IC I I. \ K -^ AKi: TKIJ-: In Til I-
lil'.sT <»l MV KNouij-.m; !•; am> I!i:i,m.i'
lsu.ll Rpsidcnrp I D I ^. 0 \JUyY\j O A f'Ue of Dedth .' "
When was diseasr ronfr.K ted, p. Qi
If not dl plarf of dcdih ? ^ 0^\) ^ ^VCVv\yav<L.^'^
Ddys
Pixrj-oi lUKiM, Ok Ki:\io\Ai, I KNiK": m i<i,\i, -.t ki;m(i\ai.
I Nl
^\,I.l,.^s 15 'X^ a1jtyO^\X^>-o Ol
N. B.-
-Kvery item otf JnW.ni.tion «ho„l.l he cnroVully suppUecl. ACK Kh,n.M he stMle.l I.X4CTLY PHVSiaANS Hhould
Htntc CAirsi: OI^ DIATH In ph.m terms, th„t It may he ,>r..,.crl> cluHnhicd. The "Spccu.l Intornu.t.on for p-r-
nons clyinji nway from home Hhould he fivcn in every instnncc.
'â– â– [
i: (
1
\'
^f
1\
M
4
n
I,;
( -
1^.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
; llc..!th i v.- 1^ ^•tr^?-'!*''^'''"" REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
.r
is
^^
JfJO'i
liOgistered J^o,
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDcatb
( XX, S. J5tanC>arC> )
(3T)
PLACE OF DEATH: — County ofOa^^ v1/ua--v^c.^c«City of 0'<X^^ J x.cu-v^^^<i co
r
Ne. ^^>UUL
.1
U^yxX'V^^iO.' ' ' St.;
Dist.; bet.
and
/ IF DEATH OCCURS AW*Y| FROM USUAL R t S I D E N C E G I V E FACTS CALLED FOR UNDER 'SPrClAL INFORMATION' \
V, IF DEATH OCCURRED IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
• I \
I) \i l: oi liiK III
A< .}•;
PERSONAL AND STATISTICAL PARTICULARS
COLOR
(Month*
/QO H
(Year)
M..nlir'
L.5-
r-
M.<nlli>
1 rai 1
l\:
^INt.I.lv M\KI<Ii;i>
\\ii>()\\i:i> nk i)i\'«)Kri:i)
'Writ- ill siicial ilrsijj'iialion)
lUKIHPI..\i>K
' Statr iir i."i)iititi \-
N \M) (»1
jaiiii;k
iiiR riiiM, AD.;
<>l" I'ArilKK
' Statf or Coiinti vl
M \I1)1;n NAM!-;
t»i M()rni-:k
inRrmn.ArK
'M Mo'lMlKR
^StaU- or C()untr>)
Rf-^'ilr'! Ill '<.iii I
'\'\\V. XiiOVl', STATI'I) I'KRSONAI, PA KT KT LA RS A U I". TR' l' I'l » III)'
iu;sT oi- Mv KN<>\vi.i:i)**.K AND in;i,n-:F
MEDICAL CERTIFICATE OF DEATH
DAIH (>1- DlCATIl
U
(Hay)
i illvKlvUV e" i{R'ri I- V, That I nttcmKd <lcrr;isiMl from
LAa.\.X5_ 5> 190 H to L^WwOl Qv"l \^^^
that I hist saw h ahvc- on VAA^V/C\ ^< \ ic)0 i
and that death orciiiti'd. 011 the (hite stati-d ahove. at » \
a
J 0
I )l RATION "^ Years
CoNTkllUTORV
Months
Pay
I/oii
) s
//ours
M.D.
I )r RAT ION )'('(?/-.v J/<>f{//is /hiys
f SIGNED) lO Xd. VJ 0-Cr^.-,
'^lAL Information only (or llospitdls, institutions, Irdnsients,
.&>^
or Recent Residents, dnd persons djin^i .iwdv from home
/>.!
nnfilMUMlll
Former or
L'sudI Residence -r —
When was dise.ise contracted,
If not at place of death ?
r\ () p 3 How lonq at ^
\Lt\jJnw^CV^ ^CvX PLire of Death? <^
Days
cu V<xX
ri.ACK 01 lU RIXL'tR RL;M<»\AL I>\TI'..! Ill kiai. ,.i ri:m(»\al
X rv\^ i^ P I CL^vo M T90H
^nmmmmmji^ymrm
X.l.ln-.s ^ I 0 O^X/C.A^Oc^O'XX.'VA^tci 0 * I
INIH-.RTXKl-K UJ,A^^XX> (lb _
« -J
iU
, ,, 1. ,1 \rr whnilil he ntiited r.\J\CTLY. PHYSICIANS should
N. B. F.very Item o? information should he cnrctully supplied. A(,r. slio. Id ''.^,.'*Y''*^;: J* ^^^ • ,„f„.,„„t J.,n" tor dt-
8t«te CAUSE OF DHATH in ph.in terms, that it muy he properly cipss.ned. The Special Information tor p.r
«on« dyinft awny from home should be Jiiven in every instance.
'^â– 'â– :ri
H],
I
h
I,
»
f
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
llr:.Hll-F- No. i> "^-t:"*'-^"' i^'^l' ^"
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
JfJO'i
dlo^^v^ \sL\y^ Deputy l-^ea!th OfTlcer
Brgislcrcd J\^().
1275
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Ccvtificatc of IDcatb
PLACE OF DEATH: — County ofO/a>^ vlAxxy^ve^AiyCi City of'Jo^^^ J'V/CX^va.ev.i>c.c
N
oM\
.KJ<XX) andVIl
rv>MxdL\_o-o./i St.; ^ Dist.;bet.Vj CrVv>CA^^> and M I t<X^crvA.
r ir DEATH OCCURS A^AV FROM USUAL R E S I O E N C E G 1 V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION • \
V IF DEATH CCCURRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME
â– UA.C .
KLkA
â– l.X
PERSONAL AND STATISTICAL PARTICULARS
Ml HIKTII
5^
t
MEDICAL CERTIFICATE OF DEATH
DA ri-; I )!• i»i: \ I'll
SIN'.l.I" M\KI<ll-:i>
\v'hm»\vi:i> (»k i)i\i iKti- 1)
'Write in sixinl di ^iviH'ti"'!'
lUKTHfl, xri-
' St;it» III < I iiiiili \-
I'A riu-.R
luuiHi'i, \ri-;
ni- lArm-.K
'St.itf I.I (•..iint t v'
<»l' MOTH IK
HIR'nn-f.AOK
or MOTIIKK
(Stale or C(»milr\ >
Ol/>v\^
o
<X yv
1 II I";K i;i'A' C I. IvTI 1"\'. TIi;it I ;ittriiik<l lift rasf.l {\<m\
\Kju<XJI 'iS Iiy')'\ to L\-\-vC» ^\ np ^
1" ( 1 ^ - V u
tli.it I la^f saw h -»-'w' alixcmi V^^a>OL_ ■* ^ Tcp^
ami that (Katli > u-nirrnl, mi llic datt,- statc-il ain \(, at I A-oO
LvM. Tlu- CAl SI; Ol" I) i: A 'I" 1 1 was as follows:
,vo
•i
DIRATION
vv>
)'taix
Mn>it/is
roNTKir.ri'oi
<L
\^
.^\X
^â– OdjfV^Xu
omi'ArioN Qv)
/^(/I's //ours
DTRATinN ^''^'/^ .Voiths /^avs
(SIGNED^ \. O. VD
c
\.^J\yOy^J^
M.D.
itdK, Instifunon^,
SPECIAL INFORMATION «nlv tor llospi
or Rt-rent Rcsidcnis, dnd persons dyin j .m.'v Iron home.
/•
Till MtoVK S'l"ATi;i) rKKSONAl, 1' \ K I" H ' T I,A K S AKI. 1" K f 1 ' 1 ' ' i " I'.
iu:sr Ol Mv K^o\\i.i:i)«",H a\i» Mi:i,n*.j-"
(Itifo-iiKint
Former or
L'sual Residence
When was disease fontrrtfted,
If not at plare of death ?
HoH Ion'] dt
PIdfe of Death ?
Transients,
Days
I'l \C1'" Ol- Id KIAI, < iK' K IM' |\ M.
1 \ I r ..! ii! 11 \! M! K i:m< >\' \ I
T90S
r M 1 1. K
f Addii s*^
N.
, ,, .. I \f:F shniiltl he stated HXACTLY. PHYSICIANS should
B.— Kvery Item of information Hhou d h. .nretulfy «uppl.c '^//J^^^^^^^^.^^ '^^e -S^.c-cinl In.'o.mation" for pT-
state CAlJSn OF DIIATH in pl.-iin terms, that it may he proptrl> ciaHsmeu. • nc j
sons dyinft away from homo should he feiven In every instance.
wy. â– *'!
1: I
r
im
ijy
IS^
il *'
I » i.
«'
I '
â– n
H
ii
:li
1
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
,,nl ..f n,:ill!i- »•• No. 1 <^ t^'^"^^- lUS: I' C.
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Duir riJr<l, (Juu^x^LA^ a^ I'^O^
Xf- ^-^ "^ '^AM, Deputy Mealth Officer
Bci^istcrod J\^(),
1276
(j-VA^^w^
^
No.
DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco
Ccitificate of IDcatb
( 11. 5. GtanDarD j
PLACE OF DEATH County of C'CUTt' -J h„<X/">XCUlCcCity ofCl/CUYV' 0 /ua^-r-uCo<L c <.
ITilD U y\ /OJ\J'^KA: St.; C) Dist.; bet. 0 AAXooa-{y\Xj and JAXL >UL>v
A„0 V^ v_A_ ...
/ IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V r FACTS CALLED FOR UNDER 'SPECIAL INFORMATION \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME
/(X-'^^aj VXX\.v duj.xix>u-\xr. (ilD /CX. K)lV'
^i:\
PERSONAL AND STATISTICAL PARTICULARS
\.
\<W\-. « )1 KlKl'lI
vc
,iu
0.S
â– â– rt-.-ir)
^< . !•.
TH
v>
.v.. ;////>
/^,M.
'Wiitiiii soiial »K>-i;.'ii;iti( 111 )
' St.'tt f or i.'i miitiv' '
NAMl-: <>1
FATIIl-.K
I'.iR rii i'i,.\rH
oi- i\thi:k
' Sf:it<' or ("â– .null \-
M\II)i:\ N\MI-.
"i .Mt»riii:K
HIRTHI'I.ACI-:
OI- MoTHKR
I
rVCrVU-v^
MEDICAL CERTIFICATE OF DEATH
nvri; oi di.atii r\
iM-Mitl)) A" (IViv) (Vc.-ir^
I HlvRIvI'.V CI.KTII'N', Tlint I aULii(lL<l ik-crasid from
YCX/>'v 10 190 S to LLvA/CL '^-^ ic>oH
AwA./a d.
that T last saw li i alivi on LLccCj, 'k I Tf/)'l
an<l that (k-atli IK currctl, on ( lie date stati-il alinvc, at I- O 0
LVM. Tlu- CM SI-: Ol" I)]-: ATI I was as follows:
I )r RAT ION
) 't'lirs
,,, ,^.^,.,.., Moui/is I /></rv \ /lours
1)1 RATION
(SIG
N E D ) M llO^ 0 OlX^'^ \-^t » '
Pavs
LLvO at i.,o'i ( A.Mrc.s) ?)bO OJKX^h 01
Hours,
M.D.
.0 'J.b T»)o'i ( A.Mn'ss) O^U VJX'aVM JV
SPEC?IAL Information "nly for llnspitdls, Instittifions.
or Rerenl Resiilents, and persons dvin,] .iw.iv from liome.
/',â– â– ,.
rin-: amovh spati'I) i'Kk^onak pxkii'Ti.xks aki-: \-\<\v. i" rm.
in-:ST Ol' MN- KN< t\\ I<i: IX". H AM) lU-.MI'.l-
nnfu!inaiit
Mv, ..^
mo
XA>A.^.xx<i.-^A^o or^
Former or
Usual Residence
When v*as disease rnntrarted.
If not at plareof deatfi?
How lonq at
Plare of Dealli ?
Transients,
. Oavs
i»\Xj:"'' iiii-'!M, <ii K i; M< iv \ I,
-^0
I'l.XCH Ol- Ml KIAI. ok ki:M«'\ \1,
INI.I.RTAKKR ^ 1 VJ )Xa.O^<i.. C<,
1 90S
(Ad.l:
N. B.-
... I- I \cv Bhf.iild i)t2 RtJitctl hX4CTLY. PHYSICIANS Hhotild
-Kvery item of i,iJ..rmHtion «hm,IH b. c..re»ull> sippl.^Ml. Af.f. kHo. I<l »»":.«Y '-u "W l„l fnformaUon" ?«r dt-
Htatc CAUSE OP DfiATM in ph.in terms, that It mny be proj.Lrly .Iuhh.V.ccI. The SpccHl Intormat.on \ur pT
sons dyinft nwoy from home kHouUI be aiven in cNcry instnnce.
\ i
Ki
k* ; \
1 r '3
1^ f \'- ' &
HI
m
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
)".,^i;.! , r II. .I'lll I' ^â– '
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
• (
i. '
ill
â– 5 ^^
illli
!>((!, ' Filed , Ll.^vx:iycvAlb :X4
v
1
.\XIl^>^y^^
//yi^A
llciHistcvvd Xn.
1277
^rWA-0 o^X/V-U
/-»/rvyi»
DEPARTJyiENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( ^1. S. St^n^nr^ )
Q^
PLACE OF DEATH: — County ofO/Ct^v J.^OXAV^Mi/t:^ Gty of^^^'^ 0.\.<X/>va^ec
u
as 11
so
No. lb 11 oUCrt^\jL4. St.; 10 Dist.;bet. ^ k.^ and
/ ,F DEATH OCCURS AWAY TROM USUAL RESIDENCE G.VE FACTS CALLED rOB UNDER S P EC AU . N FOR V, AT , O N ' A
( .r DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER, )
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
SKX A ^ kt»I,oR
l>\cJ^
I "A II Ml r.iR 111
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'^i\< ,1,1:. M\Kun:i).
\\ 1 itc in '•lu-ia ' • liiti'iii )
I'.iK ruri.AcM-:
' Stiitf or < "i lunt I V*
1 '.i\
1 /,.;/'// -
/^•
^â– \^t^ lu.
I \Tii Ik
r.iRTni'i.ArK
(>»•• l-ATHKK
(State or Country
M \ii>i:\ N ami:
"I M()i-iii-:K
iiik riiiM.Ac'F,
' stMti or (.'<»int I \
MEDICAL CERTIFICATE OF DEATH
DAI"]-; (>i- i)i:a III
(MuntlO
\l>ay* (Year)
I lli:ki:r.\' CI{R'ril'\'. 'riial I attLMi.U-(l (U-ccased from
til at I last saw h w. > alivf oti WW>*^Cl A I icp .
and that .K-atli occurred, on tin- dato statc<l above, at O
\J M. TIk' CWrSK Ol" Di'A'lMI was as follows:
vJy(vLAVv-<iA^^ VA./wX_'^-\x..
.•O-O'v ■^ \.
oiLTI'ATIoN ^ .
0 JLOO'V^-VA.Lt'X'
DT RAT ION 3s )V</r.s
CONTRIIU TORN'
Mouths
Pays
I/oitfS
DIRATION
( SIG
)'<</;-.?
Months
Pax
NED) VI), Ll.M)la/v<lo^
eAiAL IN
A
I lou)^
M.D.
Special information ""'y 'f>^ Hospitnls, Institulitms, Irdnsienls,
ni RpienI Residents, and persons dvini) av^dv from home,
lormer or '^•^ '""'' «*'
Kf^idri' in Sdii /'i (I i>i ''''i>
) 'I'lt I
\! .nlh^
MI-: AIIOVH S-IATl-D l-KRSONAL rARII'l I, \ k -^ ARI, TRI]-, To Till'
IU-:ST <)l- MV KN<»\\ I.i;j)<".K AND r.l.Mll
'Infii-ni;int
' \.l.lr.->.s
\ka
bXl JLJcrLj'^^ H
L'sudI Residence
When was disease rontrarfed,
If not at place ol deatfi ?
Plare ol Death ?
Ddys
I>1 \(F 01 lURIAI. OR R1:M«»\ \I.
'I, \ch. < II m M
I) \ II
LLlax:3i ^0
\! t ri:m(i\ai,
190H
r
\,A'^.^\-^W O
N. B.-
-F.
8
8
,•.,1 \(:n shoMhl be «tntecl F.XAOTLY. PHYSICIAMS should
ivery item of inlform.ition should be cirou.lly supplied. .^ . ....,, x,,^. "Spewlal InformHtion" for p«r-
t«tc C \lISn OP DEATH In pinin terms, thnt it m:.y be properly .laHS.t.ed. .
on* dyinfe away from home Hhould be feiven in every mntance.
I'
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RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I!o:.nl of lU:.Hh I' Vm : ". ^''l"^?-' ''"'^ »' '"
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Ihffr n/rr/, CLv^vvAt X'\ I'^OH
llegisfci'cd JS'^o.
1278
a>-u
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eath
( *Cl. S. StauDarO )
J? 05?) J? ^
PLACE OF DEATH: — County ofOctTA. 0/l<X >vc<^c(.City ofO-CV^ 0 >vCX/w^v^cc
Nf).
(
U
C^> v'v.v
St.;
Dist,; bet.-
and
.r DtAT^i OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION â– \
IF DEATH OCCURRED .N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME
fCrlw\j
JLAAJL^.
• i: \
PERSONAL AND STATISTICAL PARTICULARS
â– "" loL
i>l llIKfH
Motlllit
\' .!•;
13l
II
( l);i\^
y/.»if//^
:.rl
II
/K'
SINCI.l*, MARK 1 1: 1)
winowHi) OK i)iv» >Kri:i)
'Wiitiiu SKcinl ilt >^iJ.'1l:ltio^)
HI K I" 1 1 n.AOl-:
St.itc or C<»mitr\-
U^ /ucL{rv^^-^<^-
^<)
NAM)-: <)1
FATJIl-.R
UIRIII I'l, ATK
<>i- iAriii-;R
• Sl.itc or i'oiitit r\-'
M \ 11)»'.\ N \M1-:
"I m«)Iiij:r
HIRTliri.At'K
• )!• ^!(»■nIl•:R
(state or Conntr\)
OCCri'A'lloX
0 X.Cr Va-i
V
MEDICAL CERTIFICATE OF DEATH
DA'll': ' 'I DI'.A'lll
(Year)
M
(Month) i\ (Day)
1 HI:KI:1'.\' CI:RTII'V, That I attomk-d (UhojisciI Inmi
tliat T last saw h '• " • alivf ou \Xj^^<\ Xi up '\
aiul that death occurred, <in the <latc stated above, at I J*
\J M. The CAISI-; Ol'" DI'Aril was as follows:
Dt k A'l'loN
)'((jr
V
i
0 JU\,^y\^Oy^'\^\.'
V
//(>//r.^
DrUATION )'(ijrs Months fhjv
(SIGNED^ V] I L b.UW/-YVv^.vvA:.UL
A I T<)n I
f.
\ddresv)15'l d.VA.tLl/v Cjl
ii
I lour s
M.D.
Rr^iiU\1 !>' S.ni /'i </'/. '-' "
M
)V,;)
M.oith^
/)</!,
THi: \iu>vK srATi:i) i'Kk^<>\ai, I'AK rKti.AKs AK1-: i-kij: ro rill'
iu;sT oi' Mv KN»>\\i.i:i)<". }•: and iu;i. n-:F
(1)1
rn,„K„„ (Jv<xa1^ MK'\cWJU
â– 1
{ \(Mrc--<
iS^ov
(?^^ it
SPEOIAL Information on'y tor llaspitdls. Inslilutions rransients,
01 Recent Residents, and persons dyin.-j aw.iv from how.
Former or C^J . C^, 1 L ^ ""^"'"'' '''
Isiial Residence ^'*-^ ^ ' XfrjjUXO
When was disease contracted,
If not at place of death ?
&'»v«. Pidce
of Death? \ (U'v". Days
I'l.ACK <H-^ 1!IKIAI< <IK K1:M"\M,
V\ \(. I' < M' til l\ l.\ l< ' ov jv 1 ,
DATlloi' Hi KiAi, or RI-;Mi>\'A1.
Lvu^'
1-
30
I90H
I N I ) 1
KTAKKK 11. U). \n\0.>vlv>y >^ C
A.he. SRG'^.O..V^iHt
PHYSICIANS should
r p«r-
.1 \c\ «h,>iiltl he stilted HXACTLY. PHYSICIANS .
^. K.— F.very Item of informntlon «houI<l he carctuliy .suppl.e.l. J 'J' ^^ ,!,3««i|'icd. The "Special lnform»tlon" Jo
«tate CAUSE OF DLATH in pli.in terms, thnt .f may he properl> claHS.ncU.
sons dyinft nwny from home should he feiven in every instance.
I
i â–
â– i <#
n
I
If
li
:.\
.1
(i
m
1..
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
]le<^lsfcre(l jYo. 1-279
Hoard of lli:.!th V Sn. i =. â– *'*:. ~,?--' i-*^ I'*"''
Ihilr niril, LLvO^vvXiJ:; 'k'\ I'>0\
l<^v^i-vx>^ Deputy Health Officer
DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco
Ccvtiticnte of IDcath
PLACE OF DEATH: — County of Ca-^v 0;vCc.>va^^ ccCity of UO/^v OXO^x^c^cc
No. Il'^
ckxXA^'VA.w St.; 1 Dist.;bct. 0 \.C\>X .ind 0 AA.
,.o.ini Dc-cinFNrr riur facts called for under 'special INEORMATION \
FULL NAME VtlOAV M 1 1^ v^^c-na.
\Xtn^.'
)
^^
^l. \
PERSONAL AND STATISTICAL PARTICULARS
Lt 'I.mK
a.<
.'kCtx
i» ATI-; <)i r. I Kill
,Uh
M
iDav)
11
'\'c:ir)
/',; 1
^IM.l.I" MAkUIi:!).
\vn)o\vi-:i) OK i)!\'» ikri:i)
iWritc ill soriiil <U sii'iialiini)
lUkiHIM. \t'l".
NAMl, or
i-.\Tiii;k
K\X^<^
iukrii]M,AiK
oi- i-ATni:K
'St.'itf til (."iiimt w
MAiiii:\ N\Mi-;
n|- Moj-IiJ.R
liikruiM.Ai'i-:
oi MoTHJ-.k
(Stiiti 111 roiinli \^
11
k'r iilrJ III Siiii /'iiHh â– â– <'
MEDICAL CERTIFICATE OF DEATH
DA ri-; OI- niiATii
J^ /go ' (
(Month)/] 'I''v' (Yenr)
I ni-:Ki:HV CI:KTII-V, Tliat I altenilcd ik-cvased from
tliat I last saw h ' alive on LUa^ -aI U)o'\
,111,1 that .Katli nrourred, on the .late stated above, at I- aO
Ul M. The CM Sl{ Oi' DI'A'IMI was as follows:
DIR A TK >N -• }''tr/\ l/.'v///\
CON Tiur.ri'nRN" Co^-^a-^^
/),n<
//(i/irs
DTK ATION ^ yr<Jrs
Mouths Hoy
(SIGNED) VJV.U.- V^A,A.<yi'V<XA-^'.c ...
')^ i„oH fAd.lres.) ^0 5 d^OAJi^
(tv-Cl- vhxvJ'^
I lom <
M.D.
)■,•,// -
M..,i;h^
(1
111-; VHOVK STATi:i) I'KUSONAI, P \ K lir T I. A K s AKi: T K t I ' T« » ' 'H"
iu:si' Oi- Mv KNo\\i,i:i)(". i-: and iu.mi-.i-
( \.l(lll <-«
I
^l\ Ida..cm1jl^w^ 0±
>A.'
SPECIAL Information «"'> '"^ Hospltdls, institutions, fransients,
or Recent Residents, dnd persons dying <m.iy from home.
Former or
IsudI Residence
When was disease ronfrarted.
If not at plare of deatfi ?
HoH Innq at
Plare of Deaffi ?
Days
190 ,
,., ^C^■• 01^ HI klAI. OK KKM.^VXI, DA-n 1: • :o "V kKMoVAI.
,N,.r,K. m;i:k "'ol: <xLcU^ ^ ^-<.
(A.l.h.-s. ^Mt M>\a.^L^V<7>V yt
' ' '^ 11 A'f h(»ul«l be stnteil f.V\CTLY. I>MVSICI\NS hHoiiIiI
IN. B. r.very item of informntion should be c.rcfully suppl.^^il. ^ • , .j^;^j. xbc "Special Iniormution" V'or p«r-
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